Too often doctors fail to correctly diagnose children with asthma resulting in inhalers almost becoming a fashion accessory.
Potentially hazardous therapy
This is according to respiratory specialists in an article titled Is asthma overdiagnosed? published in the journal Archives of Disease in Childhood.
Asthma is a disease with symptoms of recurrent tight chest, wheezing or cough. The common long-term condition involves two major elements: chronic inflammation of the airways, and episodic tightness in the chest.
Professor Andrew Bush and Dr Louise Fleming of Imperial College and Royal Brompton Hospital in London claim that doctors are overdiagnosing asthma in children in the UK. Currently 1.1 million children in the UK are being treated for asthma.
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"Inhaled corticosteroids, when properly used, dramatically improve quality of life and reduce the risk of asthma attacks and mortality,” they write.
However, they caution that the overdiagnosis of asthma exposes patients to the potentially harmful side effects of medications they do not need, including adrenal failure and growth suppression and an increased risk of respiratory infections.
“Is there any other chronic disease in the world in which children are committed to potentially hazardous, long-term therapy without every effort being made objectively to document the diagnosis?”
A killing disease
Prof Bush and Dr Flemming also express concern that incorrect diagnoses and failures in basic management have resulted in childhood death.
"We propose that one contributing factor is that the diagnosis of asthma has been trivialised and inhalers dispensed for no good reason, and have become almost a fashion accessory," they write. "The result is the fact that asthma is a killing disease if not correctly managed, is overlooked."
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The experts go on to cite a small Australian study that investigated more than 100 children with chronic cough. They noted that doctors included bronchoscopy in their examination, which is something the researchers do not recommend in routine diagnostic testing.
They went on to point out that before testing, half of the children were given an asthma diagnosis, but this number dwindled to just 5 percent after the examinations.
Prof Bush and Dr Flemming recommend a more objective and careful diagnoses. However, this can be difficult as there is no definitive test.
They advise doctors to consider the use of more invasive checks such as testing nitrogen oxide levels and blood tests, adding that if a child is not getting better despite asthma medication then, instead of increasing the doses, they should consider that the diagnosis might be wrong.
The risk of trivialising asthma
Speaking to Health24, Dr Flemming indicated that the pair were prompted to write the article because they feel very strongly that asthma needs to be taken seriously and there needs to be better recognition of the potential severity of the condition.
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"Unfortunately children still die from asthma. Overdiagnosing asthma, particularly without using available tests, runs the risk of trivialising asthma. There can be consequences of both under- and overdiagnosis, hence the importance of using relevant tests," she said.
Dr Flemming said improving asthma care must start with the basics. “Making the diagnosis, ensuring the patient is on the correct treatment, ensuring they know how to use their inhalers and that they are actually taking them."
While in the past asthma was underdiagnosed, Prof Bush explained to Health24 why doctors may have gone too far in the opposite direction in terms of overdiagnosing the condition.
"I think they are worried about missing the diagnosis, they are under pressure and cut corners and sometimes it is just difficult to appreciate how much normal children cough."
Don't give normal children medication
Prof Bush highlighted the steps that doctors should follow in order to diagnose asthma:
- A careful history and physical examination should be conducted.
- Measure peak flow, which is the maximum rate at which the patient can forcefully breathe out. This can be measured with a wright min-peak flow meter.
- Look out for a response to ventolin if it is administered.
- Check for allergies.
- Continue re-assessing the child.
"It is essential to treat patients properly and not give normal children medications and attention that should be reserved for children who need them," cautioned Prof Bush.
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He also offered some advice to parents. "If you are in doubt as to whether your child needs an inhaler, don't stop it before discussing it with your doctor."
Responding to the article, Dr Samantha Walker, who is the director of research and policy at charity Asthma UK, called in a statement for more investment in asthma research to get to a definitive test to ensure people get the right diagnosis.
“It’s astonishing in the 21st century that there isn’t a test your child can take to tell if they definitely have asthma.”
She said asthma isn’t one condition but many, with different causes and triggered by different things at different ages.
Guidelines for diagnosing asthma
"Asthma symptoms also change throughout someone’s life or even week by week and day by day. This complexity means that it is both over- and underdiagnosed, in children and in adults, so people don’t get the care they need to manage their asthma effectively.
"As a result, a child is admitted to hospital every 20 minutes because of an asthma attack and asthma attacks still kill the equivalent of a classroom of children every year in the UK."
The National Institute for Health and Care Excellence (Nice), which is a health watchdog for England and Wales, is working on developing guidelines for the diagnosis and monitoring of asthma.
The draft guide instruct doctors to use more clinical tests to back up their judgement and avoid the danger of wrongly labelling someone as having asthma.
Archives of Disease in Childhood: Is asthma overdiagnosed? by Professor Andrew Bush and Dr Louise Fleming; http://adc.bmj.com/content/early/2016/03/08/archdischild-2015-309053.short?g=w_adc_ahead_tab
Professor Andrew Bush, Department of Paediatric Respiratory Medicine, Royal Brompton Hospital
Dr Louise Fleming, Clinical Senior Lecturer in Respiratory Paediatrics at the National Heart and Lung Institute
Asthma UK: Asthma UK comment on overdiagnosis media story; https://www.asthma.org.uk/about/media/news/comment-on-article-claiming-doctors-are-overdiagnosing-asthma/
NICE: Draft guideline to improve asthma diagnosis; https://www.nice.org.uk/news/article/draft-guideline-to-improve-asthma-diagnosis
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