
Challenges in the Diagnosis and Management of Asthma in Children
February 4th, 2025
Asthma is a common childhood respiratory condition, affecting around 14% of children worldwide [1]. Characteristic symptoms of asthma include wheezing, shortness of breath and coughing, usually triggered by exposure to certain allergens. Despite its high prevalence, asthma outcomes in children are still inadequate with around 20,000 hospital admissions due to asthma attacks alone in the UK each year [2]. There are also 20-35 deaths in children with asthma each year [2].
Undoubtedly there exists a need to improve the care of and outcomes for children who are suffering from asthma. This blog will describe some of the main challenges impacting the diagnosis and management of asthma in children which may be hindering the effective delivery of care.
Challenges in diagnosis
The misdiagnosis of asthma in children is common with one study reporting rates of 40-45% [3]. Typically an asthma diagnosis is made based on presenting symptoms and airflow limitation as determined by pulmonary function testing (PFT). However, the assessment of symptoms in children can be challenging as they are often intermittent and variable and not always present at the time of clinical review. Additionally, young children are often not able to provide information about their symptoms and instead diagnosis often rely on observations made by the child's parent.
Furthermore, performing PFT on children can also be a challenge. Although spirometry and peak flow measurements can be performed in those over 5 years of age they are generally not recommended in younger children as they are unlikely to perform these tests accurately. Even in children in which PFT can be performed only a proportion will display fixed airflow limitation [4,5]. Consequently, PFT may also find limited application in assessing the progress of children with asthma concerning their response to treatment.

Challenges in management
The pharmacological treatment of asthma in children is mainly driven by symptoms, despite asthma being a disease of chronic inflammation. Until recently the treatment of asthma in children relied solely on the bronchodilators such as short-acting beta 2 agonists (SABAs) rather than anti-inflammatory medications such as inhaled corticosteroids. (ICS). However, recently the use of an ICS and SABAs has been recommended in children over the age of 5 while in those under the age of 5 SABAs remain the standard of care. There are also concerns over the use of ICS in children, as their use has been associated with a temporary slowing of growth [6].
The effective treatment of asthma also rests on good adherence to asthma maintenance medication which can be a particular problem in children. A recent meta-analysis reported medication adherence rates in children with asthma ranging from 28-67% [7]. Another common problem impacting the effectiveness of asthma treatment in children is poor inhaler technique. A recent systematic review found that only 8–22% of children with asthma use their inhalers correctly [8]. Poor inhaler technique is associated with poor asthma control and more frequent hospital visits [8,9].
In addition to pharmacological treatment, another component of managing asthma in children is the avoidance of asthma triggers. Asthma symptoms can be triggered by exposure to a range of allergens including pollen, dust mites, or animals, as well as smoke, air pollution and respiratory infections. Exposure to asthma triggers can be particularly hard to control in children when they spend a significant proportion of their day outside the home environment at school where they encounter other children.
In conclusion, the diagnosis and management of asthma in children still presents significant challenges including intermittent symptoms, inability to accurately measure lung function and poor inhaler technique. The improved awareness of these challenges will undoubtedly help guide future advances in caring for children with this difficult but very treatable condition.

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References
[1] Zar HJ, Ferkol TW. The global burden of respiratory disease-Impact on child health. Pediatr Pulmonol. 2014;49(5):430–434.
[2] Asthma + Lung UK. The number of children ending up in hospital with life-threatening asthma attacks more than doubles [Internet]. 2023 [cited 2024 Nov 7]. Available from: https://www.asthmaandlung.org.uk/media/press-releases/number-children-ending-hospital-life-threatening-asthma-attacks-more-doubles.
[3] Lo D, Danvers L, Roland D, et al. Misdiagnosis of children’s asthma is common in UK primary care and can be improved with objective tests. Paediatric asthma and allergy. European Respiratory Society; 2018. p. PA1314.
[4] Martinez FD, Vercelli D. Asthma. The Lancet. 2013;382(9901):1360–1372.
[5] McGeachie MJ, Yates KP, Zhou X, et al. Patterns of Growth and Decline in Lung Function in Persistent Childhood Asthma. New England Journal of Medicine. 2016;374(19):1842–1852.
[6] GINA. GLOBAL STRATEGY FOR ASTHMA MANAGEMENT AND PREVENTION [Internet]. 2019. Available from: www.ginasthma.org.
[7] Boutopoulou B, Koumpagioti D, Matziou V, et al. Interventions on Adherence to Treatment in Children With Severe Asthma: A Systematic Review. Front Pediatr. 2018;6.
[8] Gillette C, Rockich-Winston N, Kuhn JA, et al. Inhaler Technique in Children With Asthma: A Systematic Review. Acad Pediatr. 2016;16(7):605–615.
[9] Capanoglu M, Dibek Misirlioglu E, Toyran M, et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. Journal of Asthma. 2015;52(8):838–845.