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Pediatric Reactive Airway Disease

  • Author: Eric S Chin, MD; Chief Editor: Kirsten A Bechtel, MD  more...
Updated: Feb 23, 2016


Not all children who wheeze have asthma. Most children younger than 3 years who wheeze are not predisposed to asthma. Only 30% of infants who wheeze go on to develop asthma. Reactive airway disease has a large differential diagnosis and must not be confused with asthma.

To establish the diagnosis of asthma, certain criteria should be met[1] :

  1. At least 5 years of age
  2. Episodic symptoms of airflow obstruction or airway hyperresponsiveness
  3. Reversible airflow obstruction of at least 10% of predicted forced expiratory volume in one second (FEV1) after use of short-acting beta2-agonist
  4. Alternative diagnoses have been excluded

On June 25, 2009, The American Thoracic Society and the European Respiratory Society jointly released new official standards on asthma evaluation for clinical trials and practice.[2] The Medscape Medical News article, New Guidelines Issued for Asthma Assessment, has a more detailed discussion.



Numerous environmental stimuli induce an allergen-antibody interaction, causing a release of mediators that create airway inflammation. Airway inflammation is the primary factor responsible for smooth muscle hyperresponsiveness, edema, and increased mucous production. A complex interaction occurs between inflammatory cells and airway epithelium. Mast cells, eosinophils and lymphocytes secrete mediators include histamine, tryptase, heparin, leukotrienes, platelet-activating factor, cytokines, interleukins, and tumor necrosis factor and create an environment toxic to respiratory epithelial cells by causing edema, mucous secretion, bronchospasm and increased work of breathing.

Speculation exists that all infants are born with highly responsive airways. Increased immunoglobulin E (IgE) levels have been found in those younger than 2 years. A decrease in airway responsiveness may be associated with environmental allergens, viral respiratory diseases, and hereditary factors. In children younger than 3 years, the intrapulmonary airways are so small that any lower airway infection results in diminished airway function. Other anatomical factors, such as poor collateral ventilation, decreased elastic recoil pressure, and a partially developed diaphragm, may predispose the very young child to respiratory compromise.

Rhinovirus infections are an important contributor to asthma exacerbations in children. Hence, therapies against rhinovirus might reduce the risk of severe exacerbations.[3] Fever and bronchospasm are not associated with a more severe clinical course. In fact, fever as a response to infection may have a beneficial effect and can be seen as a good prognostic indicator.[4] Recently, it has been hypothesized that severe infection with Respiratory Syncytial Virus (RSV) may be a marker of a predisposing factor for asthma.[5]

There are several theories as to prevention of bronchospasm and asthma in children. The hygiene hypothesis suggests that early exposure to infections and allergens might protect children from developing asthma later in life because of improved immune system.[4]

Breastfeeding might protect children younger than 24 months of age against recurrent wheezing. The cytokine, TGF-B1, in human milk may have both suppression and enhancement functions in the immune reaction.

Exposure to maternal environmental tobacco smoke during pregnancy or the first year appears to predispose children to reactive airway disease.

Current research on the genetic basis for the pathogenesis of asthma may lead to new diagnostic and preventive treatments. The ADAM33 gene on the short arm of chromosome 20 is hypothesized as being important in the development and pathogenesis of asthma.




United States

Pediatric asthma is a chronic, multifactorial, lower airway disease that affects 5-15% of children (2.7 million children in the United States alone). In the United States, approximately one half of all ED and clinic visits for asthma are children younger than 18 years. ED visits peak in the fall while school holidays disrupt the spread of infections resulting in a subsequent decrease in ED visits and hospitalizations. Status asthmaticus appears to be on the rise; several retrospective studies reflect an increase in hospital admissions, particularly in those younger than 4 years. Fewer hospital and ED visits occur in children using inhaled corticosteroid therapy.

Asthma prevalence appears to be increasing worldwide. Air pollutants may play a role in the prevalence increase. Higher prevalence occurs in poverty stricken urban areas where children are less likely to have routine doctor visits and access to the availability of medications.

A correlation may exist between high levels of exposure to cockroach allergen and the frequency of asthma-related health problems in inner-city children.[6] Homes in poverty areas were more likely to have high cockroach allergen levels. Asthma may develop in children from early exposure to cockroach allergen.[7] An association may exist between obesity and childhood asthma. Increased resistin, an adipokine produced by adipose tissue, may play a negative predictive role in asthma.[8]

An algorithm has been developed to determine the risk factors for developing persistent asthma symptoms among children younger than 3 years of age who had 4 or more episodes of wheezing during the previous year.[9] The Asthma Predictive Index included either (1) one of the following: parental history of asthma, a physician diagnosis of atopic dermatitis, or evidence of sensitization to aeroallergens; or (2) two of the following: evidence of sensitization to foods, ≥4% peripheral blood eosinophilia, or wheezing apart from colds.


Worldwide, the prevalence of asthma is increasing. Asthma is found to be more common in Western countries than in developing countries. Asthma is more prevalent in English-speaking countries. Prevalence increases as a developing country becomes more Westernized and urbanized.


See the list below:

  • One third of all children younger than 18 years are significantly affected.
  • Reactive airway disease accounts for 13 million health care visits annually in the United States and 200,000 hospitalizations for which approximately $1.8 billion is spent annually.
  • Mortality rates are increasing despite new pharmacologist advances.
  • European Respiratory Society (ERS) and American Thoracic Society (ATS), created a task force to evaluate and provide management recommendations for severe or therapy-resistant asthma, recognized as a major unmet need. Severe asthma is defined as requiring treatment with high-dose inhaler plus a second controller and-or systemic corticosteroids to prevent it from becoming "uncontrolled" or that remains "uncontrolled" despite this therapy. Current research based on phenotyping (epidemiology, pathogenesis, pathobiology, structure and physiology) to allow better diagnosis and targeted treatment. [10]


Reactive airway disease is more common in black and Hispanic children; hospitalization rates in African Americans are 4 times greater than in the white population. A correlation may exist between high levels of exposure to cockroach allergen and the frequency of asthma-related health problems in inner-city children.[6]

No correlation exists between education levels from a retrospective review.


The male-to-female ratio is 1.5:1.


The peak prevalence of asthma is in those aged 6-11 years.



Childhood asthma and wheezy bronchitis persisting into adulthood could lead to chronic obstructive lung disease (COPD) in later decades of life.[11]   

Contributor Information and Disclosures

Eric S Chin, MD Consulting Staff, Department of Emergency Medicine, Kaiser Permanente Hospital, S San Francisco

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Grace M Young, MD Associate Professor, Department of Pediatrics, University of Maryland Medical Center

Grace M Young, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Emergency Physicians

Disclosure: Nothing to disclose.

Chief Editor

Kirsten A Bechtel, MD Associate Professor of Pediatrics, Section of Pediatric Emergency Medicine, Yale University School of Medicine; Co-Director, Injury Free Coalition for Kids, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Additional Contributors

Debra Slapper, MD Physician, Southwest Washington Free Clinic System-Urgent Care; Former FEMA Physician and Military Contractor; Former Associate Professor, University of Miami, Leonard M Miller School of Medicine and University of South Florida Morsani College of Medicine

Debra Slapper, MD is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

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Patient peak flow record.
This nomogram results from tests carried out by S. Godfrey, MD, and his colleagues on a sample of 382 healthy boys and girls aged 5-18 years. Each child blew 5 times into a standard Wright Peak Flow Meter, and the highest reading was accepted in each case. All measurements were completed within a 6-week period. The outer lines of the graph indicated that the results of 95% of the children fell within these boundaries.
Stepwise approach for managing asthma in children 0 to 4 years of age. National Institutes of Health. National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the diagnosis and management of asthma. August 2007. NIH publication no. 07-4051. Available at: 3 Accessed December 30, 2007. PRN, As necessary.
Table 1. Peak Flow Rates in Liters per Minute [15]
Height in




Range* Height in




40 150 110-190 56 330 240-420
41 160 115-205 57 340 240-420
42 170 120-220 58 360 260-460
43 180 130-220 59 375 270-480
44 190 135-245 60 390 280-500
45 200 145-255 61 400 290-510
46 210 150-270 62 415 300-530
47 220 160-280 63 430 310-550
48 230 165-295 64 445 320-570
49 240 175-305 65 460 330-590
50 250 180-320 66 480 345-615
51 260 190-330 67 500 360-640
52 270 195-345 68 515 370-660
53 280 200-360 69 530 380-680
54 300 215-385 70 550 395-705
55 315 225-405 71 570 410-730
*Includes 95% of white males aged 7-20 years.

Derived and adapted from J Pediatr 1979;95:192-6.

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