It is important for parents to describe their child’s wheezing correctly and to check that this recipe fits the description of the child’s symptoms. Most people use the word “wheezing” to describe a wide variety of audible breath sounds, but the clinical definition is specific; In the form of a loud high-pitched, musical or whistling sound coming from the chest. When diagnosing wheezing, the following should be questioned;
• Nature and duration of wheezing, including whether it is continuous or intermittent.
Presence of other respiratory symptoms
Aggravating factors and triggers
• Previous chapters
• Smoking status of the household
Whether the child has any eczema or other symptoms or signs of atopy
• Whether there is a family history of atopy
Physical examination is primarily used to help identify potentially serious causes of wheezing. Ideally, the child’s wheezing should be evaluated during the examination to confirm that it meets the clinical definition of wheezing, but this will not always be possible.
The exam should include a general assessment of the child including respiratory rate, heart rate, temperature, and oxygen saturation (if a pulse oximeter is available). In a child with acute wheezing, the examination should assess for concurrent upper respiratory tract infection, eg. Otitis media or pharyngitis. Observe the child’s chest to assess for signs of hyperinflation and respiratory distress, such as intercostal withdrawal and use of accessory muscles. Do auscultation of the child’s chest and note any wheezing or crackling and focal sounds.
Laboratory and respiratory studies are generally not used to assess wheezing in preschool children. Further investigations such as chest x-rays are often reserved for children with symptoms from birth or wheezing that are unusually severe, unresponsive to a treatment trial, or accompanied by unusual clinical features. Peak-flow, spirometry, and other assessments of lung function are generally not used in children under the age of five, as they cannot provide a reliable and consistent result between tests.
Management of Wheezing in Children
Management of wheezing preschool children should begin with a clear discussion with parents about the possible prognosis of the child’s illness and limitations of treatment. It should be explained that the diagnosis will usually become clear over time and that pharmacological therapy can be used to relieve symptoms, but does not alter the natural course of the child’s wheezing and does not prevent the development of asthma. Because the type of wheezing can change over time before the age of five, the child’s symptoms will need to be reassessed regularly.
Lifestyle Interventions for Preventing Exacerbations of Wheezing in Children
A small child who comes with wheezing provides a good opportunity to encourage all adults in the household to quit smoking. Provide quit smoking advice and support as needed and record smoking status of family members. It should not be recommended for the mother to smoke during pregnancy. Aggravating factors such as moist housing and inadequate heating in the winter should be discussed and parents should be helped with solutions if possible, as these have been shown to reduce respiratory symptoms in childhood.
Infection prevention strategies should be discussed, especially for children with episodic viral wheezing. Children need to keep their vaccination schedule up to date and get the flu vaccine every year. Regular hand washing and good hygiene practices should be encouraged to prevent the transmission of infections in home or nursery settings. Allergen avoidance has long been discussed as an early intervention for wheezing and asthma. However, there appears to be limited benefit in trying to avoid allergies, and intervention can be difficult and costly.
Treatment of Acute Wheezing Attacks
• Bronchodilators babies with bronchiolitis generally should not be treated with bronchodilators as they provide minimal benefit.
• Children under five years of age with episodic viral or atopic wheezing may be tried in a short-acting bronchodilator for symptomatic control.
• When necessary, bronchodilator therapy should be done with a short-acting beta agonist (SABA). Salbutamol 100 micrograms is recommended, with a maximum of 800 micrograms per day for children.
• This should be administered by inhalation, using a spacer and mask. Instructions should be given regarding the correct use and cleaning of the device.
Long-acting beta-agonists (LABAs), although potentially effective for young children with wheezing, are generally not recommended as there are several strong studies showing their benefits or safety in young children.
• Theophylline is not recommended for use in children with wheezing or asthma.
In a child with acute severe wheezing requiring hospitalization, oral corticosteroids are recommended and may be given while awaiting transplant. In a child with acute severe wheezing that does not require hospitalization, the use of oral corticosteroids is less obvious and should be based on clinical judgment. Evidence for the effectiveness of oral corticosteroids in children under the age of five is limited and often conflicting, with most studies focusing on older children. If necessary, oral prednisolone can be given 1-2 mg / kg per day for a maximum of 40 mg for three days.
Corticosteroids are not recommended in preschool children as parents have not been shown to prevent exacerbations or hospitalization in this age group. Oral corticosteroids are associated with a number of side effects, including changes in appetite, mood, and behavior when used for short periods. When used for longer (more than three months), adverse effects such as reduced growth, skin changes, muscle weakness, Cushing’s syndrome, bone weakening and increased risk of diabetes can be severe.
Prevention of Symptoms
Inhaled corticosteroids Symptoms among viral episodes
In children with atopic wheezing, use of inhaled corticosteroids (ICS) should be considered. In children with episodic viral wheezing, treatment with ICS is less effective and is not widely recommended. Treatment with ICS of wheezing in children under the age of five is for symptom control only and has no effect on the long-term natural history of the condition and does not reduce the likelihood that a child will develop persistent wheezing or progress to asthma. Response to treatment with ICS in young children is generally less than that seen in older children.
Recommended ICS for children under the age of five is 50-100 micrograms of fluticasone twice a day through a spacer and mask device for up to three months. When interval symptoms improve, ICS should be stopped (after being reduced) rather than just being reduced. Short-term treatment with ICS is as effective as continuous use in preschool children and can limit side effects.
Corticosteroid use in young children can cause many side effects. Most notably, height growth was reduced with studies that found approximately 1 cm less height (which may be permanent) in children treated with ICS for two years compared to placebo. Adrenal suppression has also been observed in children receiving ICS, but impairment in adrenocorticotropic hormone (ACTH) stimulation tests may be more common than is currently recognized.
Montelukast has a role in managing episodic and atopic wheezing. Montelukast, a leukotriene receptor antagonist, is a suitable therapy for symptom and exacerbation control in children of any type of wheezing. The drug is currently subject to Special Authority subsidy criteria (see: “Montelukast Private Authority changed”). The Special Authority criteria allow for use in children with intermittent wheezing, which is currently an “off-label” use.
In wheezing preschool children, continued use of montelukast appears to moderately reduce wheezing episodes, and when the first signs of upper respiratory tract infection appear, intermittent use can help control symptoms and reduce the number of referrals to primary health care.
Montelukast can be used alone to prevent and manage wheezing flares, or can be used in conjunction with ICS to avoid having to increase the ICS dose for efficacy. Available as a chewable tablet. The recommended dose of montelukast for children aged two to five is 4 mg once a day. The ideal duration of treatment is uncertain. Twelve months of continuous treatment appears to be effective in preventing flare-ups and controlling interval symptoms. However, short-term dosing, such as seven-day cycles initiated by the parent or caregiver when symptoms occur, is also effective in controlling exacerbations and episodes and may reduce the overall combined dose of the drug. No clinically significant adverse events were reported in children receiving montelukast.
Author: Ozlem Guvenc Agaoglu