Clinical assessment of wheeze and asthma in children 1 to 5 years

In children aged 1 to 5 years with reported wheeze, confirm that the symptom is actually wheeze—parents and carers often incorrectly identify wheeze. Hearing the wheeze either in person, or via a video recording, can help confirm the symptom (see the video from The Royal Children’s Hospital [Melbourne]).

Spirometry is not feasible in children 5 years and younger, so assessment of children in this age group with wheeze relies on clinical findings. Take a detailed history and perform a physical examination to determine whether a treatment trial is appropriate, and to exclude possible alternative diagnoses.

Features in a young child that suggest an alternative diagnosis or warrant referral include focal wheeze, poor growth or developmental delay. Alternative diagnoses that can be confused with asthma also outlines conditions commonly confused with asthma in children.

The history should include details of:

• current symptoms (wheeze, cough, shortness of breath, chest discomfort or tightness, increased respiratory rate and work of breathing)
• pattern of symptoms (frequency, time of day or night)
• severity of symptoms (impact on alertness, activity and play)
• aggravating or precipitating factors (eg viral infections, exercise, laughing)
• allergies (eg atopic dermatitis, allergic rhinitis)
• exposure to second-hand smoke in the home and biomass smoke (eg indoor fires for heating or cooking)
• family history of allergies or asthma
• relieving factors (including medication trials).

The physical examination should include:

• height and weight
• chest auscultation
• inspection for chest deformity
• inspection of the upper respiratory tract for signs of allergic rhinitis, and skin for signs of atopic dermatitis.

Chest X-ray is generally not necessary for assessment of wheeze and asthma in children—it can be considered for unusual symptoms, or for suspected alternative diagnoses (eg pneumonia).

While assessment can’t definitively confirm or exclude a diagnosis of asthma in children 1 to 5 years, certain features increase the probability that a child with wheeze will have asthma in later childhood and adulthood. See Clinical features that increase and decrease the probability of a children 1 to 5 years with wheeze having asthma in later childhood and adulthood for a list of features that increase and decrease the likelihood of asthma. Although the probability of asthma does not necessarily change initial management, it can be a useful part of the discussion with parents and carers.

If the child has unusual symptoms or if an alternative diagnosis is suspected but can’t be confirmed, consider referral to a specialist for further investigation.