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Martin Luther likened human reason to a drunken man on horseback, alternately falling off to the left and then to the right.1 The same is true of diagnosing asthma; undoubtedly in the past it was underdiagnosed, but have we gone too far in the opposite direction? The evidence is that we have; for example, in an Australian paper, in which more than 100 children with chronic cough were investigated intensively, including with bronchoscopy (which we do not recommend as a routine diagnostic test!), half were given a diagnosis of asthma prior to investigation; the number actually thought to have asthma had dwindled to 5% at the end of testing.2 Although cough-variant asthma exists, it is overdiagnosed; isolated cough in the community is rarely, if even, due to asthma,3 and even in a tertiary centre, atopic children with cough only infrequently have eosinophilic inflammation.4 Key to diagnosing asthma correctly is being confident in making that most difficult diagnosis of all, normal child; and this requires detailed knowledge of the range of symptoms with upper respiratory infections in the normal child.5
Overdiagnosis of asthma clearly matters. The fiscal cost of asthma medications is not trivial. Inhaled corticosteroids (ICS), when properly used, drastically improve quality of life and reduce the risk of asthma attacks and mortality. However they have side effects, including adrenal failure and growth suppression, with increasingly worrying evidence (mainly in adults) that they cause mucosal immunosuppression and an increased risk of respiratory infections.6 There is also evidence that systemic absorption of ICS depends not just on the prescribed dose, but is greater if the dose is inappropriately high for the degree of airway inflammation.7 The National Review of Asthma Deaths8 highlights another reason why we need to get the diagnosis right. It …