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‘We can’t diagnose asthma until <insert arbitrary age>’
  1. Andrew Bush1,2,
  2. Ian Douglas Pavord3
  1. 1Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
  2. 2Leukocyte Biology, Imperial College London, National Heart and Lung Institute, London, UK
  3. 3Nuffield Department of Medicine, Mathematical Physical and Life Sciences Division, University of Oxford, Oxford, Oxfordshire, UK
  1. Correspondence to Professor Andrew Bush, Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London SW3 6NP, UK; a.bush{at}rbht.nhs.uk

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The use of low-dose inhaled corticosteroids (ICS) to treat children with asthma can be life-transforming, and this is confirmed repeatedly when they are made widely available for the first time in a low and middle income setting.1 However, reading the National Report on Asthma Deaths (NRAD)2 among other documents makes it very clear that progress has stalled. In response to this perception, a Lancet commission has recently been published.3 This annotation reviews some of the implications of that document for paediatrics.

The first proposal is that ‘asthma’ is no more than a clinical description of symptoms such as wheeze, breathlessness and cough, as arthritis describes red, painful joints; neither is a 21st century diagnosis. The proper response of a family whose child has been given a diagnosis of asthma is, ‘what sort of asthma does my child have?’ So the Commission proposes that as far as possible, the airway disease should be deconstructed into identifiable aspects such as airflow limitation, eosinophilic airway inflammation, airway infection and impaired airway defences, and altered cough reflex sensitivity and efficacy. The emphasis is on defining in particular ‘treatable traits’ of airway disease,4 which include such extrapulmonary comorbidities as obesity and allergic rhinoconjunctivitis, and social and environmental factors, in particular adherence. There are important implications of this approach in preschool children, school-age children with an associated airway or systemic disease and also in the era of the new biologicals.

The wheezing preschool child has traditionally been ‘phenotyped’ on the history as having episodic viral wheeze or multiple trigger wheeze,5 which is limited in many ways,6 and can hardly be said to be worthy of 21st century practice. Some but not all likely have eosinophilic airway inflammation, and thus be responsive to ICS. The Lancet approach is to urge characterisation of …

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