Difficult asthma: beyond the guidelines

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Abstract
The first question when confronted by a child with severe symptoms despite conventional treatment is: does the child really have asthma? There are several alternative diagnoses that should be considered, some more rare than others. Relevant investigations should be carried out when the history or examination suggests one of these other diagnoses (table 1). In particular, the presence of finger clubbing is incompatible with the lone diagnosis of asthma. An asthmatic child may be affected by another condition that contributes to or worsens the asthma symptoms. In particular, gastro-oesophageal reflux should be looked for and treated although its significance is not always clear.5 Immunodeficiencies should also be excluded; an initial screen should include serum immunoglobulins and IgG subclasses, complement concentrations, and antibody responses to common antigens (diphtheria, tetanus, Haemophilus influenzaetype b, and pneumococcus) (Jones A, personal communication, 1998).