Beliefs about diagnosing asthma in young children

Objectives. To determine what factors primary care pediatricians believe are important in establishing the initial diagnosis of childhood asthma and to identify variations in physicians' beliefs concerning this clinical decision. Study Design. Massachusetts American Academy of Pediatrics Fellows were surveyed about their beliefs concerning the importance of 20 clinical factors associated with establishing the initial diagnosis of asthma. Results. Most clinicians considered recurrent wheeze (96%), symptomatic improvement with a bronchodilator (90%), recurrent cough (89%), exclusion of alternative diagnoses (87%), and suggestive peak flow findings (82%) as important in diagnosing asthma. However, there was substantial heterogeneity among clinicians as to which combinations of factors they each considered relevant; for example, only 60% identified all 5 of the above factors to be necessary or important. Further, <50% identified presence of any of the 20 factors as necessary. Although national guidelines cite objective assessment of pulmonary function as essential, spirometry and peak expiratory flow testing were identified as necessary by only 8% and 10%, respectively. Two factors believed to contribute to establishing the asthma diagnosis contradicted the National Asthma Education and Prevention Program guidelines and expert opinion (age >2 years and absence of fever during episodes) and these beliefs were more likely held by those clinicians in practice for >5 years. Conclusions. The majority of pediatricians believe several common clinical factors establish a diagnosis of childhood asthma, but disagree over what combinations of these factors are important. Some misconceptions persist despite wide dissemination of clinical practice guidelines. We believe that future asthma guidelines will need to organize diagnostic criteria in an easily understood format, like a decision tree, to facilitate early recognition of asthma in young children.