Case report

Introduction
Asthma is a reversible, chronic inflammatory disorder of the airways which is
associated with the airway hyper-responsiveness that leads to episodes of
widespread but variable airflow obstruction.(1) The characteristic key features that
suggest high possibility of asthma are presence of wheeze, diurnal pattern of airway
obstruction, trigger-related symptoms, interval symptoms, individual or family
history of an atopic disease and positive response to asthma therapy.(2)
Daniel is a 3 year old boy who lives with parents. His father works as a factory
worker and his mother is a housewife. Daniel just started to attend kindergarten in
the January and did not have any issues in the new environment. However, he had
been absent to school very often because of his illness.

Birth history and Development

Since Daniels mother had impending eclampsia, he was delivered by lower
segment Caesarean section (LSCS) at gestational age of 25 weeks with birth weight
of 750 milligrams. He was admitted to NICU and discharged without any
complications after a period of 3 months. Due to admission to NICU, Daniel was not
breastfed. According to a recent study, children who are born before 32 weeks of
gestation have estimated 3 folds increase in risk of developing asthma compared to
those children who born at full term.(3) Other than that, breastfeeding is suggested
to be one of the protective factors of childhood asthma.(4) Prematurity and extreme
low birth weight may explain the high possibility of asthma in this case.
Daniels developmental milestones are consistent with his age. According to his
mother, he is able to walk up steps with alternating feet. He can hold a pencil
properly and do some sketching and drawing. Besides that, he can follow some
simple commands like picking up some stuff and put things into a box. For speech
and social interaction, he can involve in interactive play with other children and
communicate to others by using 3 to 5 words sentences.

Current presenting complaint

Daniel had been coughing for three days. The cough is non-productive cough and it
is more frequent at night which has brought sleep difficulty to Daniel. It is also
associated with runny nose with clear discharge. There was no fever, diarrhea and
vomiting, and any urinary symptoms. With absence of fever, Daniels mother was
not worried so much because she thought it will be resolved spontaneously after a
few days. Unfortunately, Daniel became breathlessness until difficult to talk on the
day 3. His breathing pattern was very fast and accompanied by whistling sounds.
His parents decided to send him to hospital. On admission, Daniel was managed as
severe acute asthma (See Appendix 1) after general assessment and measure the

vital signs. Oxygen, salbutamol and oral prednisolone were given and Daniel
responded well to these treatments.

Medical history (personal and family)

Daniel had an episode of severe breathlessness during 9 month old which had been
relieved by a single dose of nebulizer at the emergency department. From 9 month
old onwards, Daniel had several episodes of mild breathlessness with runny nose
but all were resolved spontaneously at home. Daniels condition was deteriorated
and he had 5 visits to the clinic in the past 4 months. Daniel has frequent cough and
runny nose followed by breathlessness. One to two doses of salbutamol with oxygen
by nebulizer could resolve the breathlessness. Other than this, Daniel does not have
any paediatric-related medical conditions and no history of hospital admission. He
has no known allergies to any medications or food. Regarding family history,
Daniels father developed eczema at the age of 2. There is no family history of
atopic asthma. The immunization is up-to-date.

Differential diagnosis
Four differential diagnosis would be considered in Daniels case.
1. Early onset of asthma
There are several points that support the diagnosis of asthma. History of
recurrent wheezing, cough and breathlessness. In addition, respond well to
asthma therapy and family history of eczema. The diurnal variation of
symptoms and triggers should be elicited to further support this diagnosis.
2. Viral induced wheeze
It is common among the children which is mostly caused by viral infection
during the first 3 years of life. It may be associated with low grade fever and
runny nose.
3. Pneumonia
History of breathlessness, cough and wheeze suggest the picture of
pneumonia. However, absence of productive cough and fever reduce its
possibility. Clinical examination of respiratory system by auscultating for endinspiratory coarse crackles and chest X-ray for the presence of consolidation
have to be done to rule out pneumonia.
4. Bronchopulmonary dysplasia
Check for any history of oxygen-dependent in the first 28 days of life and
abnormal chest X-ray to support this diagnosis.

Investigation
The diagnosis of childhood asthma is by clinically based on the characteristic
symptoms without any other diseases which may explain the symptoms.(5)
Although the diagnosis of asthma is clinically based, other tests may still be

required to confirm the diagnosis or to rule out other possible diseases. In Daniels
case, the only investigation has been done is full blood count to exclude the
possibility of any infections specifically pneumonia where the white cell count is
likely to be raised.

Investigations
Full blood count and CRP
Nasopharyngeal swab
Chest X-ray

Skin prick test

Reasons
To rule out infection
To detect presence of bacteria or virus
in the upper respiratory tract
To rule out bronchopulmonary dysplasia
To check for hyperinflation of the lung
(hyperlucent lung and flattened
diaphragm)
To screen for common allergy and find
out possible triggers of asthma

Management
On admission

Oxygen
Via facem ask/nasal prongs to correct the oxygen saturation

B2 agonist
bronchodilators
Inhaled b2 agonists are the first line treatm ent for acute asthm a

Steroid
therapy
20m g oral prednisolone

Discharge
In h a le d b 2
a g o n ist
U se a s
re q u ire d
In h a le r
te c h n iq u e
sh o u ld b e
ta u g h t to
p a re n ts
Fre q u e n c y
a n d d o sa g e
S e e k fo r
m e d ic a l h e lp
if a sth m a
w o rs e n

A sth m a d ia ry
Re co rd th e
fre q u e n c y o f
a s th m a
a tta ck s
A s th m a
sy m p to m s
Trig g e r
fa cto rs

Life sty le
m o d ifi c a tio n
A lle rg e n
a v o id a n c e if
k n ow n
B e w a re o f
exe rcise in d u c e d
a sth m a
Av o id a n ce o f
to b a cco
sm o ke

Stepwise management of asthma

By using asthma diary to record the episode of asthma attacks, the severity and
control of asthma can be monitored as well as step up the management when
necessary. (See Appendix 2)

Effect/problems
Asthma is a chronic disease that can affect an individuals life in the biopsychosocial
aspects. Biologically, asthma has a great impact on the quality of life. Daniel may
experience difficulty sleeping during acute exacerbation of bronchial asthma.
Physical activity might be also affected as exercise can exaggerate the asthma
symptoms. In term of preventing deterioration of pulmonary function, adequate
asthma management should be provided promptly to prevent permanent narrowing
of the bronchial tubes.
Psychological problems will be more significant as Daniel grows up especially at the
period of schooling. There might be issue about Daniels self-consciousness as
dependence on the inhaler might make him feel that he is abnormal compared to
his friends or classmates. Eventually, reluctance of using inhaler will precipitate
asthma and also increase the frequency of admission.
From the social aspect, recurrent clinic visit has brought extra workload to Daniels
parents particularly his mother who is taking care of him. His mother has to learn
when to give salbutamol inhaler to Daniel by using the correct technique when it is
necessary. In addition, frequent visit to clinic may also cause financial burden to the
family.

Discussion
The definitive diagnosis of asthma requires history of recurrent respiratory signs
that shows symptoms of asthma. Therefore, early detection of asthma is almost
impossible as young age children with other respiratory diseases can mimic asthmalike symptoms. With the actual diagnosis of asthma, prophylaxis treatment for
asthma can be given and this will eventually avoid unnecessary admission to clinic
or hospital. By doing so, financial burden to the family as well as the community can
be greatly reduced. From the aspect of health, early interventions in asthma may
secure the pulmonary function and also improve the quality of life.

Asthma Predictive Index (API) (6)

Castro-Rodriguez JA, et al. conducted a longitudinal study that shows children who
had a positive result of API at the age of below 3 are more likely to be diagnosed
with asthma after 6 year old. Significantly, 97% of the children with negative result
of API did not have asthma after 6 year old. API may be considered to aid the early
diagnosis of asthma.
(7)
(1389
words)

References
1.
Davidson's Principle & Practice of Medicine. Elsevier; 2010. p. 662.
2.
Lissauer T, Clayden G. Illustrated Textbook of Paediatrics. 2012. p. 285-93.
3.
Health Editor. Premature Birth Linked to Asthma, Wheezing in Childhood 2014
[cited 2016 28 April]. Available from: http://news.health.com/2014/01/29/prematurebirth-linked-to-asthma-wheezing-in-childhood/.
4.
Dogaru CM, Nyffenegger D, Pescatore AM, Spycher BD, Kuehni CE.
Breastfeeding and Childhood Asthma: Systematic Review and Meta-Analysis.
American Journal of Epidemiology. 2014.
5.
Scottish Intercollegiate Guidelines Network. British guideline on the
management of asthma. 2014.
6.
Chang TS, Lemanske RF, Guilbert TW, Gern JE, Coen MH, Evans MD, et al.
Evaluation of the Modified Asthma Predictive Index in High-Risk Preschool Children.
The journal of allergy and clinical immunology in practice.
2013;1(2):10.1016/j.jaip.2012.10.008.
7.
van de Kant KD, Jansen MA, Klaassen EM, van der Grinten CP, Rijkers GT,
Muris JW, et al. Elevated inflammatory markers at preschool age precede persistent
wheezing at school age. Pediatr Allergy Immunol. 2012;23(3):259-64.

Appendix 1
Severity of asthma

Appendix 2
Stepwise management in children less than 5 years