Paediatric Asthma Diagnostic Approach

Table 1: Probability-Based Approach of Asthma

Probability of asthma:	Low	Moderate	High
Duration of symptoms (cough, wheeze, heavy breathing) during URTI	< 10 days	> 10 days	> 10 days
Number of exacerbations	2-3 per year	>3 per year, or severe episodes	>3 per year, or severe episodes
Interval symptoms (between episodes or exacerbations)	No symptoms	Occasional cough or wheeze	Cough and/or wheeze during play/laughing/exercise
Atopy	Nil	Nil	Present
Family history of asthma	Nil	Nil	Present

Some pointers:

For high probability of asthma, a therapeutic trial of low to moderate dose ICS for at least 6 weeks may be commenced and clinical improvement with preventer treatment and worsening of symptoms when treatment is stopped is suggestive of asthma.
For low probability of asthma, evaluate for other diagnosis.
For intermediate probability of asthma, watchful waiting or a diagnostic trial of low dose of ICS for 3 months and assess response.

Table 2: Modified Asthma Predictive Index (mAPI)

Four or more wheeze episodes per year with at least 1 major OR 2 minor criteria

4 or more wheeze episodes per year

Major Criteria (0 selected)	Minor Criteria (0 selected)
Parental history of asthma	Eosinophilia (>4%)
Atopic eczema (doctor diagnosed)	Wheeze unrelated to colds
Aero-allergen sensitisation	Allergic sensitisation to food i.e. milk, egg, peanuts

Red flags and pointers of other diagnosis:

Failure to thrive
Neonatal or very early onset of symptoms
Vomiting/feeding problems with respiratory symptoms
Chronic wet cough (> 4 weeks)
Fixed monophonic wheeze/stridor
Failure to respond to controller medications
No association of symptoms with typical triggers (e.g. URTI)
Focal / asymmetrical lung findings
Cardiovascular signs
Finger clubbing
Hypoxaemia outside context of acute illness

Table 3: Evaluation of the Background of Newly Diagnosed Asthma

For each row, click the value that best matches the patient. Overall severity is set by the single most severe parameter selected (standard convention for this kind of staging table — see the formula note for why).

Parameter	Step 1 Intermittent	Step 2 Mild persistent	Step 3 Moderate persistent	Step 4 Severe persistent
Day symptoms
Night waking
Exacerbation
Exercise/activity symptoms
FEV1 / PEFR

This division is arbitrary and the groupings may merge. An individual patient's classification may change from time to time.
There are patients with infrequent but severe or life-threatening attacks with completely normal lung function and no symptoms between episodes.
PEFR = Peak Expiratory Flow Rate; FEV1 = Forced Expiratory Volume in 1 Second.

Show formula

Modified Asthma Predictive Index (mAPI): positive if ≥4 wheeze episodes per year AND (≥1 major criterion OR ≥2 minor criteria).
Severity classification (Table 3): overall step = the single most severe parameter selected, not an average or majority -- standard convention for this kind of staging table (matches GINA/NAEPP-style asthma severity classification), not stated verbatim in the source.
Table 1 (probability-based approach) has no stated points-based combination rule in the source, so it stays reference-only (not auto-scored) here.

Source: Paediatric Protocols for Malaysian Hospitals, 5th Edition. Ministry of Health Malaysia.