Noninvasive Screening Tool Identifies Preschool Patients at Elevated Risk for Asthma

According to findings from a diagnostic study, the CHILDhood Asthma Risk Tool (CHART) may identify pediatric patients at high risk for asthma as early as 3 years of age.

Researchers aimed to develop and assess a symptom-based screening tool to identify 3-year-old children at high risk of asthma, persistent wheeze symptoms, and health care burden at age 5 years, utilizing data from the CHILD study, which enrolled women and their offspring from January 1, 2008, to December 31, 2012, at four Canadian sites.

Children with a risk for future asthma and persistent symptoms were categorized by CHART as having a high, moderate, or low asthma risk based on symptoms reported before age 3 years. Asthma or persistent symptoms at age 5 years was defined by the timing and number or wheeze or cough episodes asthma medication use, and emergency department visits or hospitalizations for asthma or wheeze.

In the CHILD cohort, 3-year diagnoses using CHART, modified Asthma Predictive Index (mAPI), in-study physician diagnosis, and parent-reported external physician diagnosis were evaluated individually to predict persistent wheeze, asthma, and health care burden at age 5 years. Validation was completed in 2 external cohorts—at age 5 years in the Raine study, which is Australia’s longest-running public health study, and at age 7 years in the Canadian Asthma Primary Prevention Study (CAPPS).

Of 2,511 pediatric patients with adequate questionnaire data to apply CHART at age 3 years, 2,354 (93.7%) had available outcome data at 5 years. Additionally, 7% were classified as being at high risk, 24% at moderate risk, and 69% at low risk.

Among 220 children with at least two wheeze episodes at age 3 years, 79 (35.9%) continued to experience wheeze at age 5 years. According to their study, CHART had a greater success rate in identifying children with persistent wheezing vs physician diagnoses and mAPI at age 5 years, classifying 72 of the children as high risk (sensitivity, 91.1%; area under the receiver operating characteristic curve [AUROC] = 0.94; 95% CI, 0.90 - 0.97).

In-study physician diagnosis at 3 years identified 49 of these children (sensitivity, 62.0%; AUROC = 0.79; 95% CI, 0.74 - 0.85), and mAPI identified 33 (sensitivity, 48.5%; AUROC = 0.74; 95% CI, 0.68 - 0.80). Moreover, the CHART tool projected the greatest percentage of true-positive asthma at 5 years (sensitivity, 50.0%; AUROC = 0.73; 95% CI, 0.69 - 0.77), followed by in-study physician diagnosis at 3 years (sensitivity, 43.5%; AUROC = 0.77; 95% CI, 0.73-0.81).

The authors found that CHART also had the highest predictive rate for subsequent health care use at age 5 years, identifying 20% more children with emergency department visits or hospitalizations (AUROC = 0.70; 95% CI, 0.61-0.78) vs mAPI (sensitivity, 45.5% vs 25.0%) and around 10% more than in-study physician (sensitivity, 36.4%) and external physician diagnosis (34.4%). The CHART predictive performance for persistent wheeze was comparable in the general population Raine study in children at 5 years of age and in the high-risk CAPPS population at 7 years of age.

The authors wrote, “To our knowledge, this is the first study to develop a noninvasive tool for early detection of asthma and persistent wheeze in a general population that has subsequently been validated in general and high-risk cohorts. Next steps for high-risk individuals include the study of biomarkers for different endotypes of preschool asthma, which is necessary to improve our precision-based approach to asthma therapy.”

The authors hope that as a simple, noninvasive screening tool for children at primary care, CHART could potentially be employed routinely as part of electronic medical records introduced at infancy.


—Yvette C Terrie, BS. Pharm, R.Ph.



Reyna ME, Dai R, Tran MM, Breton V, Medeleanu M, Lou WYW, et al. Development of a symptom-based tool for screening of children at high risk of preschool asthma. JAMA Netw Open. 2022;5(10):e2234714. doi:10.1001/jamanetworkopen.2022.34714.