An 18-month-old Boy with Wheezing

Pediatric Pathways

An 18-month-old Boy with Wheezing

Our Authors

Pediatric Pathways from American Family Children's Hospital: Dr. Ann Esquivel, MD

Ann Esquivel, MD

 

Pediatric Pathways from American Family Children's Hospital: Daniel J. Jackson, MD

Daniel J. Jackson, MD

After reading this article and answering the review questions, the reader will be able to:

  1. Obtain a comprehensive history when evaluating a child with a wheezing episode
  2. Use the modified Asthma Predictive Index (mAPI) to predict the risk of asthma in preschool-aged children with wheezing
  3. Identify treatment options for preschool-aged children with recurrent wheezing
  4. Recognize when to refer a wheezing child for further evaluation and management

Case

Jack, an 18-month-old male, comes to your office with 5 days of cough and rhinorrhea, and the development of wheezing over the last 3 days. Parents report this is his fifth episode of wheezing in the past year, and each episode has been associated with a viral illness. An albuterol inhaler was prescribed after the second episode and this helped alleviate his symptoms. Mom has been giving 2 puffs of albuterol with a mask and spacer twice a day for the last 3 days. Currently, Jack’s parents deny any increased work of breathing, though they note that he has increased cough and shortness of breath with his usual play activities. He has been afebrile throughout the illness.

This is his second visit to your office for wheezing. He had 3 trips to the Emergency Department (ED) for wheezing, one of which resulted in a hospital admission. In between these wheezing episodes, he is well. Outside of viral illnesses, parents deny nocturnal cough, daytime cough, or shortness of breath with play.

His past medical history is positive for eczema, which he developed at 2 months of age. He uses topical emollients and a mid-potency topical steroid as needed. He has an albuterol inhaler with facemask and spacer that he uses on an as-needed basis. He is not allergic to any medication. His mother has asthma and allergic rhinitis, and his father had atopic dermatitis as a child. His 5-year-old sister has peanut allergy. He lives with his parents and sister in a smoke-free environment with a pet labradoodle. Jack attends day care 3 full days per week.

Physical examination: RR 44, HR 150, TEMP 99.3°F, PulseOx 97% room air. He appears ill, but non-toxic, and is in no acute distress. He has mild scleral injection bilaterally. The nasal turbinates are hyperemic and boggy with white/clear nasal drainage noted. The tympanic membranes are clear bilaterally with normal landmarks. Lungs have symmetric bilateral scattered expiratory wheezing with mild suprasternal retractions noted while he runs around the room. Cardiac examination reveals sinus tachycardia without murmurs. Abdomen is soft, nontender, and not distended. He has an erythematous dry scaling rash on his cheeks (bilaterally) and chin.

Final diagnosis: Jack has severe intermittent wheezing. This can be thought of as a wheezing subtype in preschool-aged children. Additionally, Jack has a positive modified Asthma Predictive Index, therefore he has ~55-65% chance to go on to develop childhood asthma. 

Overview of Wheezing in the Preschool-Aged Child

Recurrent wheezing episodes are common in the preschool age group. Although 50% of children wheeze in the first 6 years of life, only about 40% of these children will go on to have asthma by age 6 years. Table 1 outlines the differential diagnoses to consider in a preschooler with wheezing. Our focus will be on recurrent episodic wheezing in this age group.

Table 1. Differential diagnosis of a preschooler with wheezing

Clue

Possible Diagnosis

Sudden onset, asymmetric wheeze

Foreign object

Difficulty/choking on feeds

Congenital heart defect/failure

Neurologic disorder

Aspiration

Symptoms worse after feed, lying down, vomiting

Gastroesophageal disorder (GERD)

Irritability, vomiting, torticollis

Sandifer syndrome

Recurrent pneumonia

Aspiration

Tracheoesophageal fistula

Cystic fibrosis

Ciliary dyskinesia

Immunodeficiency

Isolated episode

Rhinovirus (RV)

Respiratory syncytial virus (RSV)

Adenovirus

Parainfluenza virus

Metapneumovirus

Severe or recurrent infections

Immunodeficiencies

Recurrent (episodic) wheezing ≥4 episodes

Asthma more likely

Continuous (non-episodic) symptoms

Anatomic cause (eg bronchomalacia)

Preschool-aged children with recurrent wheezing tend to have an episodic pattern of wheezing and are often well between episodes. The majority of the episodes are associated with viral infection (i.e.,RV, RSV, parainfluenza). Among these, wheezing with RV has emerged as the strongest predictor for future asthma. A prospective cohort study showed that children who wheezed with RV-infection in the 3rd year of life had a 90% chance of having asthma at age 6.4 Allergic sensitization often precedes virus-induced wheezing, and is an important risk factor for RV-induced wheezing episodes and asthma. Wheezing episodes increase during peak viral seasons, greatest in the fall, winter and spring, with low incidence in the summer. The modified Asthma Predictive Index (Figure 1) is a helpful tool to differentiate children who are more likely to develop asthma.3

Figure 2: Modified Asthma Predictive Index

Figure 2

If the mAPI is positive, then there is a 55-65% likelihood of developing clinical asthma at age 6.

If the mAPI is negative, then there is a 90-95% likelihood of not developing clinical asthma at age 6.

The sensitivity is low at 25% but the specificity is high at 96%.3

Evaluation

The evaluation of a preschool-aged child with a wheezing episode involves careful history taking for the current episode as well as any prior episodes. Table 2 lists the important elements to include in the history and physical exam. Laboratory workup or imaging might be necessary if infection, immune deficiency, foreign object, or anatomical abnormalities are a concern. Spirometry is generally not used in this age group, but can be helpful beginning at about 5 years of age.

Table 2. Important elements during the interview and physical exam

Interview

  • Number of wheezing episodes in lifetime and past year
  • Triggers (i.e. viral illness, pets or other allergens, smoke exposure)
  • Prior ED, urgent care visits and hospitalizations for wheezing/difficulty breathing
  • Current and prior medications used for episodes • Nocturnal cough (during and outside of wheezing episodes)
  • Shortness of breath or increased cough with play
  • Personal history of eczema or allergy
  • Family history of atopy (asthma, allergic rhinitis, food allergy, eczema)
  • Exposure to smoke or pets
  • Attendance at day care

Physical exam

  • Abnormal lung sounds (wheezing) – if asymmetric/more acute onset, consider foreign body
  • Respiratory rate
  • Work of breathing
  • Oxygenation via pulse oximeter
  • Nasal polyps – evaluate for cystic fibrosis
  • Skin exam for signs of atopic dermatitis (eczema)
  • Extremities to evaluate for cyanosis or clubbing

Medications

Short acting beta agonists

  • Preferred rescue therapy during acute episodes.
  • Even infants can be given inhalers as opposed to nebulized treatments with use of facemask and spacer. These are faster to administer and more portable than nebulized treatments.

Inhaled corticosteroids (ICS)

  •  Use of daily ICS decreases exacerbations and supplemental medications compared to placebo.5 Daily ICS also improves day-to-day control.5
  • Based on the Prevention of Asthma in Childhood6 and Preventing Early Asthma in Kids5 studies, it is clear that the use of ICS in children at risk of developing asthma does not alter the natural history of the development of asthma.
  • Daily ICS given for 12-24 months is associated with a 1.1 cm reduction in growth, which is reversible in many children after discontinuation, but can be persistent, especially when used in younger patients of lower weight.7
  • Adherence to daily ICS is low (30-50% in general pediatrics populations).
  • Intermittent high-dose ICS in the “Yellow Zone” (See Asthma Action Plan, figure 2) is an alternative: When low dose daily budesonide (0.5 mg nightly) was compared to intermittent high dose budesonide (1 mg twice daily) started at onset of respiratory tract infection symptoms and continued for 7 days, outcomes were similar and patients had significantly less total ICS exposure.8 Clinically, we often use intermittent medium-high dose fluticasone (110-220 mcg 2 puffs twice daily) for 5-7 days in the yellow zone. This plan is meant to be used 3-6 times per year. If needed more often, or ineffective, daily controller therapy should be considered.

Leukotriene receptor antagonists

  • Montelukast decreases the rate of moderate asthma exacerbations and has modest effects on systemic corticosteroid courses in 2- to 5-year-old children with intermittent asthma.9
  • Episodic use of montelukast, as in a yellow zone plan, modestly reduces trouble breathing and interference with activity; this is more evident in patients with a positive asthma predictive index.10

Oral corticosteroids

  • Oral corticosteroids are helpful for treatment of asthma exacerbations in school-aged children, teens, and adults.
  • In acute outpatient wheezing episodes in preschool children, there is limited evidence of the efficacy of oral corticosteroids, highlighting the need for novel therapies in this age group.11 When to refer 

When to Refer

According to the NIH Guidelines12, refer to an Asthma Specialist if your patient:

  • has daily asthma symptoms, frequent night symptoms, or limitation of activity
  • has had a life-threatening asthma attack or been hospitalized for asthma
  • does not meet the goals of asthma treatment after three to six months, or their doctor believes they are not responding to current treatment • has symptoms that are unusual or hard to diagnose
  • has co-existing conditions such as severe hay fever or sinusitis that complicate asthma or its diagnosis
  • needs more tests to find out more about their asthma and triggers
  • needs more instruction on treatment plans, medicines, or asthma triggers
  • has taken oral corticosteroids more than twice in one year

Conclusion

Returning to our case, our severe intermittent wheezing preschool-aged child, Jack, would be a candidate for either daily low-dose ICS therapy OR intermittent medium-high dose inhaled corticosteroid therapy. Jack should also receive a written asthma action plan (Figure 2) and instruction on proper use of an inhaler with spacer and facemask. If an intermittent yellow zone therapy approach is chosen, this should be initiated at the first sign of cold symptoms (do not wait for significant wheezing or signs of lower airway compromise), and continued for 5-7 days. If parents feel he has not improved within this time frame, they should contact his provider at 5-7 days. Jack should be seen again in 6-8 weeks following initiation of the new asthma action plan. If he has exacerbations despite the yellow zone plan or is using the yellow zone plan more than 3-6 times per year, then he should be started on daily controller therapy. ICS would be preferred compared to montelukast, particularly in a child who has had wheezing severe enough to lead to hospitalization.

Jack would also benefit from referral to a Pediatric Allergy Clinic for identification of potential allergic triggers, such as the pet dog, which might be contributing to his frequent exacerbations as well as his difficult-to-control atopic dermatitis. While most seasonal aeroallergen sensitivity does not appear until around age 3 years, sensitivity to perennial allergens such as dust mite, cat, dog, and molds, can develop earlier. In fact, early sensitization to aeroallergens is a critical risk factor for virus-induced wheezing episodes and asthma inception.13 In addition, he has now been hospitalized with a wheezing exacerbation, and requires close follow-up and careful education.

In summary, recurrent wheezing is a common problem in young children and is challenging to treat based upon the incomplete efficacy of available therapies in this population. Wheezing with respiratory viruses during the preschool years is the most common first presentation of childhood asthma. Identifying children at risk for recurrent wheezing and providing education for families and close follow up are critical in order to tailor treatment plans to the individual child with the goal of reducing morbidity associated with this frequent pediatric problem.

Go to CME questions

References

  1. Bacharier LB, Philips BR, et al. Severe intermittent wheezing in preschool aged children: a distinct phenotype. J Allergy Clin Immunol. 2007 Mar;119(3):604-10.
  2. Martinez FD, Wright AL, Taussig LM, et al. Asthma and wheezing in the first six years of life. N Engl J Med 1995;332:133-8.
  3. Castro-Rodriguez JA. Asthma Predictive Index: A very useful tool for predicting asthma in young children. J Allergy Clin Immunol. 2010 Aug;126(2):212-216.
  4. Jackson, DJ, Gangnon RE, Evans MD, et al. Wheezing rhinovirus illnesses in early life predict asthma development in high-risk children. Am J Respir Crit Care Med. 2008;178(7):667-72.
  5. Guilbert TW, Morgan WJ, Zeiger RS, et al. Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med. 2006:354(19):1985-97.
  6. Bisgaard H, Hermansen MN, Loland L, Halkjaer LB, Buchvald F. Intermittent inhaled corticosteroids in infants with episodic wheezing. N Engl J Med 2006;354: 1998-2005.
  7. Guilbert, TW, Mauger DT, et al. Growth of preschool children at high risk for asthma 2 years after discontinuation of fluticasone. J Allergy Clin Immunol. 2011;128(5):956-63.
  8. Zeiger RS, Mauger D, Bacharier LB, et al. Daily or intermittent budesonide in preschool children with recurrent wheezing. N Engl J Med. 2011;365(21):1990-2001.
  9. Bisgaard H, Zielen S, Garcia-Garcia ML, et al. Montelukast reduces asthma exacerbations in 2- to 5-year-old children with intermittent asthma. Am J Respir Crit Care Med. 2005;171(4):315-22.
  10. Bacharier LB, Phillips BR, Zeiger RS, et al. Episodic use of an inhaled corticosteroid or leukotriene receptor antagonist in preschool children with moderate-to-severe intermittent wheezing. J Allergy Clin Immunol. 2008; 122(6):1127-35.
  11. Beigelman A, King TS, Mauger D, et al. Do oral corticosteroids reduce the severity of acute lower respiratory tract illnesses in preschool children with recurrent wheezing? J Allergy Clin Immunol. 2013; 131(6):1518-25.
  12. National Heart, Lung and Blood Institute. Expert Panel Report 3. Guidelines for the Diagnosis and Management of Asthma 2007. Bethesda, Md: National Institutes of Health; Aug. 2007. NIH Publication No. 07-4051.
  13. Jackson DJ, Evans MD, Gangnon RE, et al. Evidence for a causal relationship between allergic sensitization and rhinovirus wheezing in early life. Am J Respir Crit Care Med. 2012;185(3):281-5.

Back to top