Special considerations for the child with airway disease

Abstract

The patient’s history is the most important part of the evaluation of allergic disease. Adults provide their own history and can integrate the details into a relevant clinical picture. In pediatric practice, the individual providing the history is more often a parent or guardian. Ideally, this historian is the mother, or most observant caretaker, and can provide an accurate account of the child’s symptoms (Table I). How the issues listed in Table I affect the overall quality of life of the child is very important. An unknowledgeable or unobservant caretaker may not be able to provide important data. Even a very aware parent may not realize the impact of symptoms if they occur during the night and the parent is not awakened, or they occur at school, especially with exercise.1 The symptoms of respiratory disorders must be assessed with several factors in mind. The average young child has 6 to 8 viral upper respiratory infections per year, each lasting 7 to 10 days. Otitis media and persistent otitis are very frequent problems in the pre-schoolage child.2 Congenital anomalies that might affect the development of respiratory symptoms must always be considered. Cystic fibrosis and gastroesophageal reflux are not uncommon and should also be considered. The possible significance of allergy in contributing to childhood respiratory disorders must be carefully teased out of this historical background. When the caregiver is vague or cannot recall details, the diagnostic process becomes more difficult. Another prevalent difficulty is the reluctance of many physicians to entertain the diagnosis of asthma in the young child. Because up to 49% of children have at least one wheezing episode before 6 years of age, this hesitation is very easy to understand.3 However, there is clear evidence that failure to diagnose asthma results in undertreatment of this condition.4 Poorly managed asthma can have a significant impact on school performance, especially because the pattern of absences tends to consist of frequent, brief periods.5-7 Although many physicians compromise in this situation with the diagnosis of reactive airways disease, it is not clear whether this results in adequate care, since the underlying inflammatory component is not addressed; therefore, cases marked by episodes of wheezing may need to be treated as if they were asthma. Very young children have smaller airways in proportion to their alveoli than do adults. Therefore, respiratory illness in this population may progress more rapidly to severe obstruction, desaturation, and respiratory failure. There is often much less tolerance for delay in caring for very young children. With adolescents, although the warning signals of a respiratory disorder may be present, problems with self image, self-esteem, and risk-taking may lead to denial of symptoms and postponement of effective treatment.8 The physical examination may or may not supply substantial information. It may be completely normal in children who suffer from intermittent respiratory disease. Telltale clues, such as a crease across the nose, may suggest allergic rhinitis, or an increased anteroposterior diameter of the chest may suggest inadequately treated asthma, with hyperexpansion of the chest being the only indication of this. The classic physical findings of a high, arched palate, dark circles under the eyes, and a constantly open mouth only identify children with nasal obstruction; they do not necessarily indicate an underlying allergic etiology. Diagnostic testing of children is another area of difference from adults. It is not always recognized that infants, even newborns, can have a positive allergy skin test if they have produced a sufficient quantity of specific IgE.9 Most often, infants who are atopic and produce specific IgE direct it against food antigens. Indeed, food is the most significant and frequent source of allergens From the Allergy/Immunology Department, Walter Reed Army Medical Center, Washington. Reprint requests: Laurie Smith, MD, Assistant Chief, Allergy/Immunology Department, Walter Reed Army Medical Center, Washington, DC 20307. J Allergy Clin Immunol 1998;101:S370-2. Copyright © 1998 by Mosby, Inc. 0091-6749/98 $5.00 1 0 1/0/86491 TABLE I. Issues related to the history of the pediatric patient