HOW SEVERE IS THE CHILD'S ASTHMA?
Once a diagnosis is made, additional information should be gathered to classify asthma severity, which is the intrinsic intensity of the disease.6 The initial classification of asthma severity is made before the child is taking long-term control medication. Severity classification is based on the domains of impairment and risk (Figure 2). Children are classified as having intermittent, mild persistent, moderate persistent, or severe persistent asthma on the basis of the assessments of both domains.
The assessment of impairment in children younger than 5 years is based on the frequency of symptoms, nighttime awakenings, and reliever use of SABAs, as well as the child's ability to engage in age-appropriate activities. The level of impairment is based on the most severe category in which any feature occurs. Recurrence of symptoms or SABA use more than 2 times a week indicates persistent asthma. Nighttime awakenings and even minor limitations in activities are also indicators of persistent disease in this age-group. Children with minimal or no impairment may have persistent disease depending on their risk domain. Therefore, it is important for HCPs who diagnose intermittent asthma in a child to periodically revaluate the child for frequency and severity of exacerbations.
The assessment of risk is based on the frequency of exacerbations.6 Generally, young children experience about 4 to 6 “colds” per year, particularly in the fall and winter months.17 In preschool- and school-aged children, hospitalizations and ED visits for asthma begin to increase every September and peak in the early fall,18-20 which is associated with an increase in viral respiratory tract infections. 18,21 For very young children, however, data to link exact frequencies of exacerbations with different levels of asthma severity are inadequate. A preschooler may have exacerbations in the absence of daily symptoms between attacks. A child who has only 1 exacerbation a year may be classified as having intermittent asthma. What is important is that children with intermittent asthma can have severe asthma exacerbations. According to the guidelines, a child with 2 or more exacerbations within 6 months requiring treatment with an OCS, even without symptoms in between, is considered to have persistent asthma. However, this recommendation is based on panel consensus judgment and clinical experience because the clinical literature addressing the subject was insufficient (Evidence level D).6