Dropping the A-bomb

 

Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.

Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.

Are you going to tell her that her son has bronchitis? A second bout of bronchiolitis? A chest cold? A simple upper respiratory infection with some wheezing? Or are you going to drop the A-bomb on her and tell her that her son has asthma? Will you try to soften the message by telling her it’s just a “touch of asthma”? How about saying he’s got “asthmatic bronchitis?”

Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”

You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.

Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.

It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.

Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.

It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).

If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.

Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.

Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.

Are you going to tell her that her son has bronchitis? A second bout of bronchiolitis? A chest cold? A simple upper respiratory infection with some wheezing? Or are you going to drop the A-bomb on her and tell her that her son has asthma? Will you try to soften the message by telling her it’s just a “touch of asthma”? How about saying he’s got “asthmatic bronchitis?”

Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”

You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.

Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.

It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.

Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.

It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).

If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.

Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].

 

Your first patient of the day is a 2½-year-old who has a runny nose and a cough. His mother has brought him in because his cough is more frequent and persistent than she is accustomed to hearing. He is happy and playful, and has a low-grade fever. You notice that he is slightly tachypneic, and you hear fine wheezes scattered throughout his lung fields. You also recall that at age 6 months, he was diagnosed with bronchiolitis but was never hospitalized.

Will you give him antibiotics and send him home with a nebulizer? Just the nebulizer? Just the antibiotics? Neither? We can debate those answers for hours, and you can plead for more information before you commit to an answer. But let’s skip over the question about what you are going to do and focus on what you are going to say. I want to know what diagnosis you are going to share with this mother.

Are you going to tell her that her son has bronchitis? A second bout of bronchiolitis? A chest cold? A simple upper respiratory infection with some wheezing? Or are you going to drop the A-bomb on her and tell her that her son has asthma? Will you try to soften the message by telling her it’s just a “touch of asthma”? How about saying he’s got “asthmatic bronchitis?”

Or are you going to try a pseudoscientific smoke screen and tell her that her that her son has “reactive airway disease”? You could soften it even further by reassuring her that his diagnosis is so common that it has an abbreviation: “We usually just call it RAD.”

You may not have trouble telling a parent that her child has asthma, but most clinicians struggle with dropping the A-bomb. Why? It may be that we don’t want the family to freak out. You could end up spending the rest of the morning coaxing them back off the ledge because you have diagnosed their child with a chronic illness that could kill him. This kind of exaggerated reaction is far less of a problem now than it was 30 or 40 years ago. Almost every parent knows at least one family with an asthmatic child who seems to be doing just fine. In my opinion, this apparent increase in prevalence of asthma is primarily the result of an improved awareness and a relabeling phenomenon.

Your own experience probably reflects the national statistics that less than a third of preschoolers with recurrent wheezing still have asthma by the time they finish kindergarten. And you may be hesitant to use the asthma diagnosis because you don’t want to be labeled as a clinician who cries wolf.

It may be that subconsciously you are afraid that by raising the asthma red flag you will be committing yourself to the time gobbling task of managing another patient with a chronic disease. You could gamble that he will only have one or two more episodes of wheezing, and you will be able to treat his illnesses simply as a short series of unconnected events.

Is there any harm in dancing around the asthma diagnosis? The authors of a Perspectives article in the January 2017 issue of Pediatrics argue persuasively that vague descriptive and nondiagnostic terms such as “reactive airways disease” are confusing and should be abandoned (“RAD: Reactive Airway Disease or Really Asthma Disease?” Pediatrics. 2017 Jan. doi: 10.1542/peds.2016-0625). They question why we would treat a condition with asthma medications and not call it asthma just because a child will probably out grow it later.

It’s more than just about sloppy language. Jose A. Castro-Rodriguez, MD, a physician who has pioneered one of the tools than can be used to predict persistent asthma in young children, observes that by failing to signal to parents that the child has a chronic condition, we run the risk that the child will be less adherent to the medication and management program we recommend. (“The Asthma Predictive Index,” Curr Opin Allergy Clin Immunol. 2011;11[3]:157-61).

If we are going to tighten up our language and drop the vague substitute terms like RAD, and if we are hesitant to drop the A-bomb because it sounds too much like a lifelong disease when the truth is that most young children will outgrow asthma, what should we tell all those parents of wheezing preschoolers? The authors of the article in Pediatrics have several suggestions. Their favorite and the one that appeals most to me is toddler asthma. As they observe, the term “toddler asthma” implies an endpoint and the need for reevaluation to determine if the child is one of the minority who has “real” asthma.

Although it’s almost always about the money. When it's not about the money, it's usually about the labels we use.

 

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including “How to Say No to Your Toddler.” Email him at [email protected].