Summary of paediatric asthma national guidelines: focusing on diagnosis
| Guideline | Year | Diagnostic criteria | Recommended objective testing | When to refer to a specialist | When to consider alternative diagnoses |
| NICE Guidelines (UK)49 | 2017 | Under 5 years: findings in clinical history and examination that are suggestive of asthma Over 5 years: findings in clinical history and examination that are suggestive of asthma and either spirometry demonstrating obstructive airflow and bronchodilator reversibility or a FeNO level of 35 ppb or more | Over 5 years: Spirometry and bronchodilator reversibility or FeNO first line. Additional tests, PEF, bronchial challenge test with histamine or methacholine | Children who are not responding to treatment and/or cannot complete objective testing If there is obstructive spirometry but negative bronchodilator reversibility and negative FeNO | When children have symptoms of asthma but normal objective testing results |
| Global Initiative for Asthma (global)20 | 2021 | 6 years and over: findings in clinical history that are suggestive of asthma plus evidence of variability in expiratory airflow limitation with either spirometry and bronchodilator reversibility, repeated PEF measurements, positive exercise challenge or positive bronchial challenge | 6 years and over: either spirometry, PEF, exercise challenge or bronchial challenge to detect variability in lung function | Diagnostic uncertainty, previous life-threatening attack, no/poor response to asthma treatment | Atypical asthma features, atypical clinical examination findings, for example, cardiac murmurs |
| Canadian Thoracic Society (Canada)32 | 2021 | Aged 1–5 years: more than one presentation of asthma-like symptoms plus a response to asthma treatment trial Over 6 years: findings in clinical history that are suggestive of asthma plus spirometry showing obstructive expiration and demonstration of reversibility of airflow limitation of at least 12% | Over 6 years: spirometry and bronchodilator reversibility (first line) additional tests that may be useful: peak flow variability, bronchial challenge and exercise challenge | Diagnostic uncertainty, severe asthma, previous life-threatening attack, need for allergy testing, any hospitalisation as a result of asthma | |
| National Asthma Council Australia (Australia)30 | 2021 | Aged 1–5 years: findings in clinical history and examination that are suggestive of asthma plus a response to treatment trial with SABA and/or ICS 6 years and over: findings in clinical history and examination that are suggestive of asthma plus spirometry demonstration of reversibility of airflow limitation of at least 12% | Aged 1–5 years: none 6 years and over: spirometry first line Bronchial challenge test and exercise testing to be considered if spirometry results do not show a reversibility of airflow limitation of at least 12% | When child has characteristic asthma symptoms and diagnosis is not clear from objective testing results | Atypical asthma features No response to treatment trials Results of objective testing do not suggest asthma |
| ARF NZ (New Zealand)31 | 2020 | Aged 1–11: findings in clinical history that are suggestive of asthma plus a response to asthma treatment trial | Aged 5–11 years: Spirometry should be considered if asthma symptoms are atypical or in those with typical asthma symptoms that do not respond to a treatment trial. | When there is no response to asthma treatment trials and/or there is diagnostic uncertainty | Atypical asthma features |
| Irish College of GPs (Ireland)50 | 2020 | Under 6 years: findings in clinical history that are suggestive of asthma Over 6 years: findings in clinical history that are suggestive of asthma plus evidence of obstructive airflow limitation and reversibility with bronchodilators | Under 6 years: treatment trial Over 6 years: PEF or spirometry. | Parental concern or request, failure to respond to treatment trial, failure to thrive, diagnostic uncertainty | |
| The Japanese Society of Allergology (Japan)27 | 2020 | All ages: findings in clinical history that are suggestive of asthma plus a response to asthma treatment trial | Lung function testing (non-specified), skin prick testing, bronchodilator reversibility testing, bronchial challenge | Poor response to multiple-agent therapy or multiple courses of oral steroids | Atypical asthma features, no response to treatment trial or atypical results on objective testing |
| International Consensus on Pediatric Asthma (global)25 | 2015 | Under 5 years: findings in clinical history that are suggestive of asthma Over 5 years: findings in clinical history that are suggestive of asthma plus spirometry with bronchodilator reversibility demonstration of reversibility of airflow limitation of at least 12% | Over 5 years: spirometry first line PEF is useful for aiding. FeNO and skin prick testing for detecting allergic asthma can be useful. | ||
| GEMA (Spain)24 | 2009 | Under 6 years: findings in clinical history that are suggestive of asthma Over 6 years: findings in clinical history that are suggestive of asthma plus spirometry with bronchodilator reversibility demonstration of reversibility of airflow limitation of at least 12% | 6 years and over: spirometry with combined bronchodilator reversibility. FeNO and allergy testing may be useful if diagnosis is unclear. | ||
| Ministry of Health (Singapore)26 | 2008 | All ages: findings in clinical history and examination that are suggestive of asthma | No objective testing normally required for diagnosis. PEF at every consultation and spirometry at least annually in children over 6 years to assess asthma severity. Tests that may be considered: CXR to exclude foreign bodies and chronic LRTIs, skin prick testing to detect atopy and exercise testing to assess exercise induced asthma | High-risk patients with poor control, young age and poor response to treatment trial, when requiring high doses of steroids to control symptoms | – |
Resources, in terms of equipment and appropriately trained staff to perform testing in children, are substantial limitations in primary care at present. Ideally PEF, spirometry and FeNO could be performed in primary care. With the addition of skin prick testing and blood work in secondary care and bronchial challenge and exercise testing reserved for tertiary care.
CXR, chest X-ray; FeNO, fractional exhaled nitric oxide; ICS, inhaled corticosteroid; LRTI, lower respiratory tract infection; NICE, National Institute for Health and Care Excellence; PEF, peak expiratory flow; ppb, parts per billion; SABA, short-acting beta agonist.