Yes, preschoolers can develop asthma!

“I'm still getting told from families and other physicians that you can't make a diagnosis of asthma until they're six. Why?  Why is this still happening? We can diagnose preschoolers with asthma.”  -- Dr. Tiffany Wong

Join Dr. Mariam Hanna as she sits down with Dr. Tiffany Wong who pushes back on the persistent and unfounded skepticism about whether preschoolers can be diagnosed with asthma. Dr. Wong is an associate clinical professor at the University of British Columbia and the medical lead of the BC Children's Hospital allergy clinic. She covers the intricacies of diagnosing and managing preschool asthma, dispels common myths and emphasizes the importance of accurate diagnosis and effective management in young children.

On this episode:

Diagnosing Preschool Asthma:

Dr. Wong clarifies the myths and realities of diagnosing asthma in preschool children. She emphasizes that a detailed medical history and physical examination can often suffice, debunking the misconception that spirometry is always necessary.

Management Strategies:

Gain insights into effective management strategies for preschool asthma. Dr. Wong discusses the importance of categorizing patients according to their risk of future exacerbations, which helps in tailoring treatment plans for both healthcare providers and families.

Follow-Up Care:

The critical role of regular follow-up in managing preschool asthma is highlighted. Dr. Wong stresses that continuous monitoring allows for better understanding of each patient's evolving clinical narrative and ensures timely adjustments to treatment plans.

Empowering Families:

Learn how to support families dealing with preschool asthma. Dr. Wong provides valuable tips on training families to recognize and report symptoms accurately, ensuring they are equipped to manage their child's condition effectively.

Tune in to this episode for a deep dive into preschool asthma, with practical tips and expert insights for both healthcare providers and caregivers.

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Find Dr. Hanna on X, previously Twitter, @PedsAllergyDoc or CSACI @CSACI_ca

The Allergist is produced for CSACI by PodCraft Productions

Transcript

Dr. Mariam Hanna: Hello, I'm Dr. Mariam Hanna and this is "The Allergist," a show that separates myth from medicine, deciphering allergies and understanding the immune system. 

 You've got your barky cough, your wet cough, your seal cough, your rattlers, the wheezing ones, the dry cough, the croupy one, the post-nasal drip cough, the bronchitis cough, the tight cough, the throat-clearing cough. Have I missed one? Oh yeah, the asthmatic cough. But actually, they never come in and report that one on their own volition. When we discuss preschool asthma in my clinic, families often inform me that they were told their child was simply too young to make the diagnosis. It seems easier to call it anything but asthma and subject the child to oral steroids, Emergency room visits, courses of antibiotics, x-rays, all to avoid or ignore the obvious diagnosis in the room. It's a vicious cycle and one that's really challenging to break when so much of the key elements of diagnosis and control come from the caregiver's history. Today's episode is really meant to set the record straight on the definition, incidence, and management of what we're seeing far too often these days in clinic: preschool asthma. Today's speaker freely endorses how much she enjoys assisting families in navigating the challenges that come with treating preschool asthma. Allow me to introduce Dr. Tiffany Wong. Dr. Wong is an associate clinical professor with the Faculty of Medicine at the University of British Columbia and is the current BC Children's Hospital allergy clinic medical lead. Her primary areas of interest are pediatric asthma, food allergy, and drug allergy delabeling. She holds several leadership positions within UBC and the province, monitoring trainees and faculty members through their quality improvement projects. She has worked in the multidisciplinary severe asthma clinic at BC Children's for nearly a decade, which is the exact population we're going to explore and discuss a lot today. Dr. Wong, thanks so much for taking time to join us and welcome to the podcast.

Dr. Tiffany Wong: Thank you so much. I'm so excited to be part of this.

Dr. Mariam Hanna: Okay, so we're going to start with a quick opener here. How do we make the diagnosis of preschool asthma?

Dr. Tiffany Wong: Okay, I'm so glad that you asked this because after a decade of working with asthmatics, I'm still getting told by families and other physicians that you can't make a diagnosis of asthma until they're six.

Dr. Mariam Hanna: See, it's perfect.  

Dr. Tiffany Wong: And I was like, why? Why is this still happening? But it is. You know, it reminds me that there's still so much education that needs to be done in all arenas. So, traditional asthma diagnosis, if you look at guidelines and definitions, you need respiratory symptoms consistent with asthma. So that includes cough, wheeze, shortness of breath, and evidence of reversible airway obstruction, usually with a breathing test. And so there's this widespread belief that you need the test in order to diagnose, and it's completely untrue. So what the diagnosis requires is an understanding of what a patient is experiencing, even when they're not old enough to do a PFT. And even when they are old enough to do a PFT, it doesn't provide all the data. You need to know whether a patient has asthma or whether you're managing it properly. You need to have the clinical context so we can diagnose preschoolers with asthma. And what we need is a medical history, and a very detailed one. So in lieu of pulmonary function tests, we can use our physical exam to confirm reversible airway obstruction. So we listen for cough, wheeze, shortness of breath, and then ideally, you give a bronchodilator and then you reassess afterward . So if they get better after you give a bronchodilator or oral steroids, or a trial of inhaled steroids, then that is a good clue that they have asthma. Alternatively, we can accept a convincing parent report of symptoms with response to a trial of inhaled steroids for at least three months. But this requires us to train the families as to what they're looking for and how they report the symptoms over the past decade.

Dr. Mariam Hanna: Have things changed over time in how we diagnose preschool asthma? Like, why are we still having this argument in clinic? I'm baffled.

Dr. Tiffany Wong: Still, it's a great question. I think there's just a lot of misinformation about what asthma is. So I think what confuses healthcare providers and patients over time are the varying terminologies. So there's like reactive airway disease, there's intermittent asthma. And these terms are a bit of a fad-like, they stick around a while and then they become unpopular for various reasons. And depending on w here we are in our training, we kind of hang on to those things that we learn. So these days, reactive airways disease is not considered something that we would diagnose a patient with because it's not very descriptive. It doesn't actually explain what's happening with the patient. And so I think there have been some changes in how we describe asthma, but it's still the same disease process.  

Dr. Mariam Hanna: It's baffling sometimes. Once you actually have the diagnosis out or the family is actually ready to accept the diagnosis, the very next question they ask is, like, will they have this for the rest of their life?

Dr. Tiffany Wong: Yeah, that is a very common question. And so once you've gotten past the point where, and I tell the families categorically this is asthma, as soon as I can, because it doesn't help the families if we're waffling for too long. Once an asthma diagnosis is confirmed, then we can talk about what things are going to look like for the long term. So I usually break it down into sort of shorter-term management, what things are going to look like over the next year, and then we talk about what things will look like over the next few years. The answer to prognosis or resolution rate really depends on the phenotype of the patient. There's a lot of data and a lot of articles coming out about phenotype in adult asthma, which is a bit easier to clarify given all the investigations that adult allergists and pulmonologists can do. But we're very limited in terms of what we can actually get from preschoolers. And so we do try to keep it simple for families because they're often very overwhelmed early on. So for preschool asthmatics who don't have any other atopic conditions, if they are just having symptoms with colds, they are more likely to outgrow by early school-age years. Those patients who have other features such as atopy, food allergy, eczema, family members with lots of atopy, especially those that are difficult to treat, those ones are less likely to outgrow over time. And that's why careful follow-up and monitoring are important. There is a tool that many of us use called the modified asthma predictive index, and it uses all the things I just discussed, in order to determine the likelihood of outgrowing asthma over time. But it's not a crystal ball.

Dr. Mariam Hanna: So if you have a positive score on this modified asthma predictive index, what is the likelihood of resolution? What do you usually tell families?

Dr. Tiffany Wong: Yeah, so I do. I tend to avoid specific numbers as I think people actually really hang on to it. So I just say exactly that, if the score is positive, you are less likely to outgrow by the time you're in early school year, so grade three, four, five. If it's negative, you are more likely to outgrow but, you know, they're preschoolers, they change. In the next two years, you could become positive on the modified asthma predictive index, and then the outlook changes.

Dr. Mariam Hanna: That's super important because I often find parents hold on to numbers like the millimeters of a number of skin tests like it is 100% going to guarantee what their future looks like. So that's actually a very nice nugget right there. The differential diagnosis, I think, is not talked about enough. What typically is your differential diagnosis? Or what are your red flags that you're looking for when a patient comes in for queried asthma?

Dr. Tiffany Wong: So the most common differential diagnosis I see is recurrent viral upper respiratory tract infections without asthma, and this can be very tricky to sort out on an outpatient basis. So it's easy when you're in the Emerg or admitted to the hospital to assess the patient and identify variable airway limitation. But when a patient comes to your office and gives you a history of eight months of cough, that's a bit harder. Preschoolers in daycare are sick very frequently, and it can seem to parents that their child is coughing forever. And so we have to look for what they look like outside of their colds as well. So are they having symptoms of wheeze, shortness of breath, cough between illnesses, with activity? And activity in a preschooler is not just running around. They don't engage in high-level sports the way older children or adults do. So things like laughing really hard or crying really hard, that's activity to a preschooler as well. So if they're wheezing with crying fits or coughing to the point where they're throwing up, those are really key features that can make you suspicious for actual asthma. Another common thing I see as a differential is environmental allergies. Being an allergist, that's actually a very common question. Is my kid allergic? And truthfully, seasonal allergies are far less common in this age group. They just have not had enough exposure. Indoor allergens may be contributing, and we can often figure this out by taking a good history. I am surprised over time by the number of three-year-olds who have evidence of indoor allergen hypersensitization, but it is generally less common. So maybe a contributing factor, but usually not the main problem. For red flags, for me, it's always failure to thrive and poor response to therapy. In both of these cases, I do start an investigation looking for lower airway diseases, including bronchopulmonary dysplasia, cystic fibrosis, bronchiolitis obliterans, basic immunodeficiency workup is always really important. Although those conditions are rare, we do miss them if we don't look for them. And sometimes I see large airway obstructions that look like asthma, tracheomalacia, vascular rings, foreign bodies. But usually, we can tell by taking a really careful history which way we should be pointing our investigations towards.

Dr. Mariam Hanna: I like your red flags, though. Failure to respond to therapy because the therapies are so good, and then failure to thrive. Common red flag for pediatrics. This is actually perfect.

Dr. Mariam Hanna: So what is the goal? We can't prevent kids from catching a cold, but what is the goal of treating an asthmatic and why?

Dr. Tiffany Wong: Yeah, so I have different goals for families and different goals for healthcare providers. So there's a lot of information and I try to keep the messages few and clear. So for parents, our goals of treatment are to keep the child out of the Emerg and prevent the need for oral steroids. And this requires us to find the right combination and dose of medications. So that is my main message to parents. And because I do follow up closely over time, it gives us many touchpoints over the next year to slowly unpack all of their questions and what their concerns are. For healthcare providers, my goals of treatment are to encourage everyone to follow up, especially because we're so dependent on parental report and physical exam findings. We really need to be able to see these patients regularly over time. And if not us, the allergist, then make sure they're connected with someone who is comfortable with preschool asthma 

Dr. Mariam Hanna: How do you approach kind of treating these guys and escalating therapy? And when do you need to do that?

Dr. Tiffany Wong: Yeah, I think what I really like is the most recent Canadian Thoracic Society guidelines. And so there are lots of guidelines. I was actually smiling because I listened to your podcast with Dr. O'Keeffe, and he was saying, pick a guideline and stick with it. And I thought that's so true because there are so many and they're all, there's a saying in Thailand, they always say, same, same, but different, right? And so these guidelines are exactly that. They're similar, but with slight differences. And if you get too in the weeds with them, you can get easily confused. The most recent CTS guidelines have actually brought some of their recommendations in line with the GINA guidelines, which does help. But what they've done is had a really large focus on risk. And this is how I approach all my patients, even before the guidelines came out. But when they came out, I thought this is what I've been doing, and now we have a way to explain this to everybody else. So I look at how likely the patient is to have a subsequent severe exacerbation in the future. So the high-risk patients are the ones who've already had a severe exacerbation. And that can be as simple as an Emergency visit, a hospital admission, received oral steroids by a family physician, and of course, anyone who's been in the ICU. And so for those patients, I tend to be much more conservative. I am quicker to step up if I don't think they are responding to the current therapy that they're on. Patients who have poor control, for whatever reason, those patients, I tend to watch very carefully, and anyone who's overusing their short-acting beta-agonist. So if you're needing two or more devices in a year and actually using them, that's too many. And so for those patients, I do tend to stick to that nice ramp, if possible.

Dr. Mariam Hanna: In pediatrics, we do a lot of this off-label medication prescribing, but it tends to be a little bit worse with preschoolers in that a lot of the medications that we could consider ramping up to would be largely off-label, especially if they are in combination devices, or even for that child's age. How do you approach this and how do you have these discussions with families?

Dr. Tiffany Wong: This is a common thing, especially among severe asthmatics.  You kind of exhaust what you have available to you. And that's okay. We just have to be comfortable with it. So if we are going to go to off-label use of medications, and usually we're talking about combination ICS, LABA medications, for preschoolers, I am really honest about it with families. It isn't first-line therapy in my practice. So if I'm thinking about using something off-label, it's because the standard indicated therapy hasn't been working well, and families usually understand it by that point. And so I explain to them that it's off-label, but just because it's off-label doesn't mean it's not safe. And we are very careful about monitoring over time. And so I think those discussions are important to have early on. And just to be frank and upfront about it.

Dr. Mariam Hanna: I almost feel like sometimes we need to discuss the concerns we have of untreated asthma. 

Dr. Tiffany Wong: I think it's really important to help families understand the dangers of presenting or requiring hospital admissions and the oral steroids. Sure, it helps the asthma quickly and that's often what parents see. They're like, well, we can just go to Emerg and get this oral steroid and then it's good for a while. But most of them are fortunate to not immediately see any adverse effects from these high doses of steroids. So we have to explain to them what the risks are of high dose steroids over time. And we have more and more evidence these days about the risks of even one dose of oral steroids for our asthmatics. So I spent time explaining that to the families, and I show families. I'm like, look, you may have 1 cm overall of height loss using inhaled steroids over time, but look how much a patient who's having uncontrolled asthma isn't growing right. The body is working way too hard just to breathe. And your child also can't grow well if the asthma is uncontrolled, and I do find those conversations, if you take time to explain to families, it does help.

Dr. Mariam Hanna: Yeah. What other challenges do you commonly face in caring for preschool asthmatics?

Dr. Tiffany Wong: Well, we've talked about it a little bit, but getting a history is a huge challenge in this age group. Teasing out recurrent colds from asthma, even when you have asthma being formally diagnosed, they come back, it's like, oh, well, they had a cold, but was this a true asthma exacerbation? And then again, like, every time you see the patient, we end up talking about possible environmental allergens. Do they have a new environmental allergy? Maybe. It takes time and a really strong line of questioning with intention in order to get a history. An organized parent is gold. But the reality is that most parents, they don't keep track of symptoms and events because they actually necessarily know what's important. So that's where our expertise comes in. I find the other huge challenge is the logistics of delivering medications on a regular basis. And so for so many reasons, young children are already a lot of work just at baseline. Adding a medication with multiple steps can be really challenging, especially if the child is uncooperative. I think we don't fully appreciate how hard this is on a daily basis for an exhausted parent and a kid who's just not participating. So the parent and the child really have to come to an understanding that this medication needs to be given consistently and with proper technique. And remembering the medication requires that every care provider participates, like mom and dad or whoever else is looking after the child. And especially because the standard medications we use for preschoolers, they don't have counters on them, right? So that requires families to be organized as well to remember when their medications are running out. I had this lovely, well-meaning family just a few weeks ago who swore up and down, they're like, we're doctor, we're giving the medicine every day. We never miss doses. And when I checked the prescription fills on the online database, I said, well, but you're two months late. And they said, no, we're doing it. And it turns out that they were giving an empty inhaler to their child because they just forgot that it would run out and they were seeing the propellant. So these are things we learned from families over time in terms of adding to our teaching and also reminding them upfront when we start therapy that these types of things can happen and to watch out for them.

 Dr. Mariam Hanna: A little bit more into the art of management, especially now that we're talking about some kids are more likely to resolve over time versus others. At what point are you considering stepping up because things aren't working well or stepping down because we've been doing really well and taking a break off medications?

Dr. Tiffany Wong: Yeah. So I do find step-up therapy a lot more straightforward. We have the nice ramp, and you know, in our teaching, we are taught to move up the ramp, so as long as adherence and technique are appropriate and the asthma is not well controlled, we have good ways of assessing asthma control. I step up the dose or add another medication. Step-down therapy is more complex.

Dr. Mariam Hanna: That's the one the parents want to discuss first, right? Like the kid's been great, let's take them off right now.

Dr. Tiffany Wong: Always. And again, I go back to risk. So for anyone who's high risk, I just call it out right there and then for the family, your son or daughter is at high risk for asthma exacerbations, for hospitalization, for Emerg visits, etc. These patients need to have good control on an inhaled corticosteroid medication for a minimum of a year before I consider any step-down.

Dr. Mariam Hanna: Dr. Wong said one year. One year.

Dr. Tiffany Wong: One year.

Dr. Mariam Hanna: One year, that's right. Okay. Very important number. Okay, keep going.

Dr. Tiffany Wong: So if you've been admitted or in Emerg or needed oral steroids or even especially multiple doses, one year. And I think that helps lay the foundation for families so they don't ask at every visit when can we step down, or if they do, I just give them the same answer one year from when you last were uncontrolled. And I don't step down during high-risk periods for families. So if it's a    virus that has triggered significant asthma exacerbations, then the winter is not the best time to step down. I am more relaxed in lower-risk or mild asthmatics, so I consider drug holidays for sure over the light spring, over the summer months, as long as we don't also have other triggers that may be involved. So if you have a severe grass pollen allergy, the summer may not be the best time to step down. And actually, in British Columbia, we have had a lot of problems with forest fires in the last few years. And they peak in August. So now that may not even be a great time to step down because of horrendous air quality issues, depending on where the family lives. So it's highly individualized.

Dr. Mariam Hanna: Yeah, but worth discussing. Right.

Dr. Tiffany Wong: Absolutely. And I think if we don't have these discussions with families, then our buy-in with therapy also declines over time. They want to know that there's an end or just a break in sight. And I'm okay with that, just as long as we all understand the risks involved. So if we're doing a holiday over the summer, they need to have a clear understanding, and I need to be confident that they understand what to do if their child ends up in the yellow zone. If you end up in Emerg in June with a cold, then we need to have a different discussion about the drug holiday.

Dr. Mariam Hanna: Right. Speaking of holidays, it's time to wrap up already.

Dr. Tiffany Wong: All right.

Dr. Mariam Hanna: Time to wrap up and ask today's allergist, Dr. Tiffany Wong, for her top three key messages to impart to patients and physicians on today's topic, preschool asthma. Dr. Wong, over to you.

Dr. Tiffany Wong: All right, so one, asthma can be diagnosed in preschool children. No spirometry is required, just a great history and physical examination if possible. Two, categorizing patients according to risk for future asthma exacerbations is really helpful in terms of guiding asthma management for preschoolers, both for the healthcare provider and also for the families as well. Three, follow-up of these preschool asthmatics at regular intervals is critical. Children are constantly changing, and having access to the patient and examining them over time is really critical to gaining a good understanding of the clinical narrative of our patient. We need to get comfortable identifying the patients over time who are at high risk and targeting them for priority follow-ups.

Dr. Mariam Hanna: Perfect. Thank you, Dr. Wong, for joining us on today's episode of "The Allergist."

Dr. Tiffany Wong: Thank you.

Dr. Mariam Hanna: This podcast is produced by the Canadian Society of Allergy and Clinical Immunology. "The Allergist" is produced for CSACI by PodCraft Productions. The views expressed by our guests are theirs alone and do not necessarily reflect the views of the Canadian Society. This podcast is not intended to provide any individual medical advice to our listeners. Please visit www.csaci.ca for show notes and any pertinent links from today's conversation. The Find an Allergist app on the website is a useful tool to locate an allergist in your area. If you like the show, please give us a five-star rating and leave a comment wherever you download your podcasts and share it with your networks because it's all about discussing risks and discussing holidays. Thank you for listening. Sincerely, "The Allergist."