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Background: Diagnosing asthma in children represents an important clinical challenge. There is no single gold-standard test to confirm the diagnosis. Consequently, over- and under-diagnosis of asthma is frequent in children., Methods: A task force supported by the European Respiratory Society has developed these evidence-based clinical practice guidelines for the diagnosis of asthma in children aged 5-16 years using nine Population, Intervention, Comparator and Outcome (PICO) questions. The task force conducted systematic literature searches for all PICO questions and screened the outputs from these, including relevant full-text articles. All task force members approved the final decision for inclusion of research papers. The task force assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach., Results: The task force then developed a diagnostic algorithm based on the critical appraisal of the PICO questions, preferences expressed by lay members and test availability. Proposed cut-offs were determined based on the best available evidence. The task force formulated recommendations using the GRADE Evidence to Decision framework., Conclusion: Based on the critical appraisal of the evidence and the Evidence to Decision framework, the task force recommends spirometry, bronchodilator reversibility testing and exhaled nitric oxide fraction as first-line diagnostic tests in children under investigation for asthma. The task force recommends against diagnosing asthma in children based on clinical history alone or following a single abnormal objective test. Finally, this guideline also proposes a set of research priorities to improve asthma diagnosis in children in the future., Competing Interests: Conflict of interest: E.A. Gaillard reports consultancy work for Boehringer Ingelheim with money paid to the University of Leicester; investigator led research grants from Circassia, Gilead and Chiesi Ltd; research collaboration with Medimmune. Conflict of interest: C.E. Kuehni has nothing to disclose. Conflict of interest: S. Turner has nothing to disclose. Conflict of interest: M. Goutaki has nothing to disclose. Conflict of interest: K.A. Holden has nothing to disclose. Conflict of interest: C.C.M. de Jong has nothing to disclose. Conflict of interest: C. Lex reports other (lecture fee paid to institution) from Novartis, outside the submitted work. Conflict of interest: D.K.H. Lo has nothing to disclose. Conflict of interest: J.S. Lucas reports grants and non-financial support (provision of equipment) from Circassia, outside the submitted work. Conflict of interest: F. Midulla has nothing to disclose. Conflict of interest: R. Mozun has nothing to disclose. Conflict of interest: G. Piacentini has nothing to disclose. Conflict of interest: D. Rigau acts as ERS methodologist. Conflict of interest: B. Rottier has nothing to disclose. Conflict of interest: M. Thomas reports personal fees from GSK, Boehringer Ingelheim and Chiesi, outside the submitted work. Conflict of interest: T. Tonia acts as ERS Methodologist. Conflict of interest: J. Usemann reports personal fees from Vertex, outside the submitted work. Conflict of interest: O. Yilmaz reports non-financial support for meeting attendance from Abdi Ibrahim, other (lecture fees) from Novartis, outside the submitted work. Conflict of interest: A. Zacharasiewicz has nothing to disclose. Conflict of interest: A. Moeller has nothing to disclose., (Copyright ©The authors 2021. For reproduction rights and permissions contact permissions@ersnet.org.)

Introduction: Diagnosing asthma in children remains a challenge because respiratory symptoms are not specific and vary over time., Aim: In a real-life observational study, we assessed the diagnostic accuracy of respiratory symptoms, objective tests and two paediatric diagnostic algorithms (proposed by the Global Initiative for Asthma (GINA) and the National Institute for Health and Care Excellence (NICE)) in the diagnosis of asthma in school-aged children., Methods: We studied children aged 5-17 years who were referred consecutively to pulmonary outpatient clinics for evaluation of suspected asthma. Symptoms were assessed by parental questionnaire. The investigations included specific IgE measurement or skin prick tests, measurement of exhaled nitric oxide fraction ( F eNO ), spirometry, body plethysmography and bronchodilator reversibility (BDR). Asthma was diagnosed by paediatric pulmonologists based on all available data. We assessed diagnostic accuracy of symptoms, tests and diagnostic algorithms by calculating sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and area under the curve (AUC)., Results: Among 514 participants, 357 (70%) were diagnosed with asthma. The combined sensitivity and specificity was highest for any wheeze (sensitivity=75%, specificity=65%), dyspnoea (sensitivity=56%, specificity=76%) and wheeze triggered by colds (sensitivity=58%, specificity=78%) or by exercise (sensitivity=55%, specificity=74%). Of the diagnostic tests, the AUC was highest for specific total airway resistance (sR tot ; AUC=0.73) and lowest for the residual volume (RV)/total lung capacity (TLC) ratio (AUC=0.56). The NICE algorithm had sensitivity=69% and specificity=67%, whereas the GINA algorithm had sensitivity=42% and specificity=90%., Conclusion: This study confirms the limited usefulness of single tests and existing algorithms for the diagnosis of asthma. It highlights the need for new and more appropriate evidence-based guidance., Competing Interests: Conflict of interest: C.C.M. de Jong has nothing to disclose. Conflict of interest: E.S.L. Pedersen has nothing to disclose. Conflict of interest: R. Mozun has nothing to disclose. Conflict of interest: D. Müller-Suter has nothing to disclose. Conflict of interest: A. Jochmann has nothing to disclose. Conflict of interest: F. Singer reports grants from the Schweizerische Gesellschaft für Cystische Fibrose (CFCH) and personal fees from Novartis and Vertex, outside the submitted work. Conflict of interest: C. Casaulta has nothing to disclose. Conflict of interest: N. Regamey has nothing to disclose. Conflict of interest: A. Moeller has nothing to disclose. Conflict of interest: C. Ardura-Garcia has nothing to disclose. Conflict of interest: C.E. Kuehni has nothing to disclose., (Copyright ©ERS 2020.)

Introduction: There are few data on the usefulness of different tests to diagnose asthma in children., Aim: We assessed the contribution of a detailed history and a variety of diagnostic tests for diagnosing asthma in children., Methods: We studied children aged 6-16 years referred consecutively for evaluation of suspected asthma to two pulmonary outpatient clinics. Symptoms were assessed by parental questionnaire. The clinical evaluation included skin-prick tests, measurement of exhaled nitric oxide fraction ( F eNO ), spirometry, bronchodilator reversibility and bronchial provocation tests (BPT) by exercise, methacholine and mannitol. Asthma was diagnosed by the physicians at the end of the visit. We assessed diagnostic accuracy of symptoms and tests by calculating sensitivity, specificity, positive and negative predictive values and area under the curve (AUC)., Results: Of the 111 participants, 80 (72%) were diagnosed with asthma. The combined sensitivity and specificity was highest for reported frequent wheeze (more than three attacks per year) (sensitivity 0.44, specificity 0.90), awakening due to wheeze (0.41, 0.90) and wheeze triggered by pollen (0.46, 0.83) or by pets (0.29, 0.99). Of the diagnostic tests, the AUC was highest for F eNO measurement (0.80) and BPT by methacholine (0.81) or exercise (0.74), and lowest for forced expiratory volume in 1 s (FEV 1 ) (0.62) and FEV 1 /forced vital capacity ratio (0.66), assessed by spirometry., Conclusion: This study suggests that specific questions about triggers and severity of wheeze, measurement of F eNO and BPT by methacholine or exercise contribute more to the diagnosis of asthma in school-aged children than spirometry, bronchodilator reversibility and skin-prick tests., Competing Interests: Conflict of interest: C.C.M. de Jong has nothing to disclose. Conflict of interest: E.S.L. Pedersen has nothing to disclose. Conflict of interest: R. Mozun has nothing to disclose. Conflict of interest: M. Goutaki has nothing to disclose. Conflict of interest: D. Trachsel has nothing to disclose. Conflict of interest: J. Barben has nothing to disclose. Conflict of interest: C.E. Kuehni has nothing to disclose., (Copyright ©ERS 2019.)

Chronic respiratory symptoms, such as cough, wheeze and dyspnoea, are common in children; however, most research has, with the exception of a few large-scale clinical cohort studies, been performed in the general population or in small, highly-selected samples. The Swiss Paediatric Airway Cohort (SPAC) is a national, prospective clinical cohort of children and adolescents who visit physicians for recurrent conditions, such as wheeze and cough, and exercise-related respiratory problems. The SPAC is an observational study and baseline assessment includes standardised questionnaires for families and data extracted from hospital records, including results of clinically indicated investigations, diagnoses and treatments. Outcomes are assessed through annual questionnaires, monthly symptom reporting via mobile phone and follow-up visits. The SPAC will address important questions about clinical phenotypes, diagnosis, treatment, and the short- and long-term prognosis of common respiratory problems in children. The cohort currently consists of 347 patients from four major hospitals (Bern, Zurich, Basel and Lucerne), with 70-80 additional patients joining each month. More centres will join and the target sample size is a minimum of 3000 patients. The SPAC will provide real-life data on children visiting the Swiss healthcare system for common respiratory problems and will provide a research platform for health services research and nested clinical and translational studies., Competing Interests: Conflict of interest: P. Latzin reports receiving personal fees from Gilead, Novartis, Roche, Schwabe, Vertex, Vifor and Zambon outside the submitted work.