The age at what asthma can be diagnosed has been subject to debate from many years. Those who have been “in the trenches” for a while remember different phases in the way which recurrent wheeze in infants have been named. “Wheezy bronchitis” was the first term I was taught to use when infants presented several episodes of wheeze during the first year of life. Then it came “Infant asthma” as a way to diagnose the same condition in a specific age, no matter whether that was anticipated to be a chronic disease (more compatible with the term “asthma”. More recently, and probably due to the lack of absolute certainty of the evolution of recurrent wheezing in an infant, the descriptive term “wheezing” (either recurrent or not) seem have gained most popularity.
In the present issue of Allergologia et Immunopathologia, Moral et al. 1 have made a very interesting and tiresome exercise to know whether asthma could be contemplated as a diagnosis in guidelines. Furthermore, they tried to know which the criteria were for diagnosing asthma at an early age (provided the guideline agreed with this diagnosis). The authors reviewed 23 guidelines which included some mention to infant or preschool asthma treatment and concluded (not surprisingly) that “There is generalized though not unanimous agreement that asthma can be diagnosed in preschool children”. However, if we perform a “stratifies analysis”, it is of interest that only three of those guidelines (actually two, as the third one is an update of a previous one) 2–4 are specifically devoted to preschool children (under six years of life). Considering those two, the final score would have been an even result, as the one produced by a European Task Force (first published in 2008 and updated in 2014) suggests that the term “asthma” should be avoided in this age; while the one from Canadian Thoracic Society and Canadian Paediatric Society sustains that asthma can be diagnosed in children older than one year of age.
Also of interest is a second paper in this issue which adds new data to the “Estudio Internacional de Sibilancias en Lactantes” (EISL), this time, from Setubal, Portugal. According to the study protocol, “infant wheeze” prevalence was measured in children at the age one year. Mallol et al. 5 do not use the term “asthma” in their paper but contrarily and descriptively “wheezing” and “recurrent wheezing”. Although it has no scientific weight, the two papers seem to agree in the idea that of using the term “asthma” during the first 12 months of life should be discarded.
It is definitely very difficult to defend with scientific arguments any position. In some way it depends on the expectations that are put on the diagnosis. It is quite difficult to anticipate a classical life-time adult asthma (with ups and downs) during the first years of life no matter which algorithm or score might be used; and thus, the “asthma” term could not be properly used. However, some children with recurrent wheeze share most asthma features, such airway reversibility (from symptom improvement), eosinophilia or atopy, which are common with adult asthma, very early in life. Those are the ones who tend to maintain the condition in time, but not of all them.
It seems that unless we do not find the ultimate marker we will not really know when asthma should be diagnosed. The problem is: a marker of what?
