Asthma Management Handbook

Further investigations for wheezing in children aged 1–5 years

Recommendations

Consider allergy tests (skin prick test or specific IgE assay) for common aeroallergens for children with recurrent wheezing when the results might guide you in (either of):

  • assessing the prognosis (the presence of allergies in preschool children increases the probability that the child will have asthma at primary school age)
  • managing symptoms (e.g. advising parents/carers about management if avoidable allergic triggers are identified).

Notes: Allergy tests are not essential in the diagnostic investigation of asthma in children. The finding of allergic sensitisation on skin-prick testing or specific IgE does not necessarily mean that it is clinically important.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Last reviewed version 2.0

Arrange chest X-ray if the child has unusual respiratory symptoms or if wheezing is localised. Routine chest X-ray is not otherwise recommended in the investigation of asthma symptoms in children.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Measurement of exhaled nitric oxide is not recommended as a diagnostic test for asthma in routine clinical practice.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Brand et al. 2008 1
  • Dweik et al. 2011 2

Routine microbiological investigations are not recommended in the investigation of symptoms that suggest asthma.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • Brand et al. 2008 1

Last reviewed version 2.0

Offer referral to a specialist for further assessment and investigation if the diagnosis is unclear or if a serious condition cannot be ruled out. 

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Relationship of allergies to asthma

Asthma can be atopic or non-atopic. Atopic asthma, characterised by eosinophilic airway inflammation associated with sensitisation to aeroallergens (positive skin prick test or specific immunoglobulin E on serology) is the more common form in children.3

The links between asthma and atopy are unclear.4 Many children with asthma are also atopic and have eczema, hay fever, or food allergies, but not all children with atopy develop asthma.4

Eczema and allergic rhinitis are risk factors for developing asthma.5, 6, 7, 8, 9, 10 Parental atopy has been identified as a risk factor for asthma in several studies, but the strength of the association differs between populations.11

A family history of atopy or asthma, or a personal history of atopy are generally considered to increase the probability that wheezing in children is due to asthma.

The association between allergic rhinitis and asthma may reflect the common allergic causes of both conditions, rather than a causal link.10 However, few studies have examined interactions between genes and environment for asthma and for atopy in the same population, and there is not consistent evidence that similar gene–environment interactions are common to asthma and atopy.4

Last reviewed version 2.0

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Allergy tests in children

Skin-prick testing

Allergy tests have a very limited role in the clinical investigation of asthma. They may be useful to guide management if the child is sensitised to aeroallergens that are avoidable (e.g. advise parents  against getting a cat if skin-prick testing has shown that the child is sensitised to cat allergens, or advise parents that there is no need to remove a family pet if the child is not sensitised).

Skin-prick testing is the recommended test for allergies in children.

Risk factors for anaphylaxis during skin prick testing are thought to include asthma (particularly uncontrolled or unstable asthma), age less than 6 months, and widespread atopic dermatitis in children.12 As a precaution, the Australasian Society of Clinical Immunology and Allergy (ASCIA) advises that skin prick testing should be performed only in specialist practices for children under 2 years and children with severe or unstable asthma.12 ASCIA’s manual on skin prick testing lists other risk factors.12

Total serum IgE testing

In children aged 0–5 years, total serum immunoglobulin E measurement is a poor predictor of allergies or asthma.1

Specific serum IgE testing

Among children aged 1–4 years attending primary care, those with raised specific IgE for inhaled allergens (e.g. house dust mite, cat dander) are two-to-three times more likely to have asthma at age 6 than non-sensitised children.1 Sensitisation to hen’s egg at the age of 1 year (specific IgE) is a strong predictor of allergic sensitisation to inhaled allergens at age 3 years.1

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Further investigations in children aged 1–5 years

In preschool children, further investigations (other than allergy tests) are not necessary and are generally not helpful.1

Investigations in a preschool child may be justified in any of the following circumstances:1

  • symptoms are present from birth
  • airway obstruction is abnormally severe
  • recovery is very slow or incomplete (resulting in prolonged or repeated hospital admission in the first few years of life)
  • episodes continue in the absence of a viral infection
  • when parents are very anxious.

Last reviewed version 2.0

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References

  1. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from: http://erj.ersjournals.com/content/32/4/1096.full
  2. Dweik RA, Boggs PB, Erzurum SC, et al. An Official ATS Clinical Practice Guideline: Interpretation of Exhaled Nitric Oxide Levels (FeNO) for Clinical Applications. Am J Respir Crit Care Med. 2011; 184: 602-615. Available from: http://ajrccm.atsjournals.org/content/184/5/602.long
  3. Comberiati P, Di Cicco ME, D'Elios S, Peroni DG. How much asthma is atopic in children? Front Pediatr. 2017; 5: 122. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5445121/
  4. Turner S. Gene-environment interactions-what can these tell us about the relationship between asthma and allergy? Front Pediatr. 2017; 5: 118. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28589116
  5. van der Hulst AE, Klip H, Brand PL. Risk of developing asthma in young children with atopic eczema: a systematic review. J Allergy Clin Immunol. 2007; 120: 565-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17655920
  6. Pallasaho P, Juusela M, Lindqvist A et al. Allergic rhinoconjunctivitis doubles the risk for incident asthma – results from a population study in Helsinki, Finland. Respir Med. 2011; 105: 1449-56. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21600752
  7. Rochat MK, Illi S, Ege MJ et al. Allergic rhinitis as a predictor for wheezing onset in school-aged children. J Allergy Clin Immunology. 2010; 126: 1170-5.e2. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21051078
  8. van den Nieuwenhof L, Schermer T, Bosch Y et al. Is physician-diagnosed allergic rhinitis a risk factor for the development of asthma? Allergy. 2010; 65: 1049-55. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20132162
  9. Morais-Almeida M, Gaspar A, Pires G et al. Risk factors for asthma symptoms at school age: an 8-year prospective study. Allergy Asthma Proc. 2007; 28: 183-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17479602
  10. Shaaban R, Zureik M, Soussan D et al. Rhinitis and onset of asthma: a longitudinal population-based study. Lancet. 2008; 372: 1047-57. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18805333
  11. Bjerg A, Hedman L, Perzanowski MS et al. Family history of asthma and atopy: in-depth analyses of the impact on asthma and wheeze in 7- to 8-year-old children. Pediatrics. 2007; 120: 741-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/17908760
  12. Australasian Society of Clinical Immunology and Allergy (ASCIA), Skin Prick Testing Working Party. Skin prick testing for the diagnosis of allergic disease: A manual for practitioners. ASCIA, Sydney, 2013. Available from: http://www.allergy.org.au/health-professionals/papers/skin-prick-testing