Continuing our series highlighting presentations from our Pulse Live and Virtual events, paediatric respiratory consultant Dr Cara Bossley outlines her top tips for diagnosing and managing wheeze in preschool children
Preschool wheeze is very common, affecting around a third of children by 3 years of age. It is defined as more than one confirmed wheeze episode prior to the age of 6 years.
In primary care it is important to ascertain the diagnosis and look for red flags.
1. Check it is true wheeze
Firstly make sure the child is presenting with true wheeze; sometimes noises thought to be wheeze are not. Playing a recording of true wheeze can be helpful.
Children can have up to 10 colds per year and often have symptoms which can last 2 weeks after this. Post-bronchiolitic cough is very common and can go on for a long time after the initial infection. It is important to differentiate between a normal ongoing cough and true wheeze or an asthma-like syndrome.
A minor common condition such as post-nasal drip can also precipitate some cough in a young child, due to their airways being narrow; ensure any such conditions are ruled out or treated.
Remember that isolated dry cough is rarely asthma.
Preschool children will rarely be able to perform any lung function tests, so the diagnosis will mainly be made on the history and examination alone.
2. Look for red flags
As always it is essential to rule out serious illness. Clues in the history can point to a more serious condition. For example, a protracted wet cough is not normal and warrants more extensive investigation and treatment. Aspiration is an important cause of wheeze in young children; check that there is no history of choking with feeds or vomiting.
Timing of onset of wheeze can provide clues to its aetiology. If wheeze has occurred from birth, it is more likely that there is a congenital or anatomical abnormality which may need to be further investigated. Chronic stridor is an important clinical sign and indicates an upper airway abnormality which is not asthma. A weak cry can also indicate a laryngeal abnormality and both of these conditions may warrant referral to an ENT surgeon.
If there is a history of prematurity the wheeze is probably more likely to be related to chronic lung disease of prematurity which may be better treated by a paediatrician.
In cases of sudden-onset wheeze, especially if the signs are unilateral, then an inhaled foreign body should be suspected and urgent referral is required. Undetected foreign body inhalation can lead to long-term problems including bronchiectasis.
3. Follow NICE to treat true toddler asthma/wheeze
In line with recently updated NICE guidelines on asthma, a trial of treatment for 8-12 weeks of low-dose ICS should be given using an MDI and appropriate spacer device. If the symptoms resolve on this trial of treatment, then try stopping the inhaler and see if the symptoms recur. If they do recur, or an acute episode of wheeze occurs, then low-dose ICS should be re-started. The dose of ICS can be titrated to a moderate dose if required. If the asthma is still uncontrolled, then you should consider adding in a leukotriene receptor antagonist at this stage.
If the wheeze does not respond to the inhaler and the basics are checked (see next point) then you should consider referring to a paediatrician.
4. Get the basics right
If symptoms recur or do not respond to treatment, always check the correct basic care has been implemented. Ensuring proper inhaler technique and using the correct spacer for the child’s age and size can make a significant difference. It’s also essential to have the parents on board with the treatment plan, as they will be administering it at this age.
It is also important to address environmental triggers for asthma like passive smoke, dampness, mould and allergens. Simple allergy testing can be beneficial in identifying specific allergens that may be triggering symptoms.
Other measures like reducing pollution exposure and supporting weight loss in cases related to obesity are also helpful to reduce wheeze.
Dr Cara Bossley is a consultant in paediatric respiratory medicine at King’s College London
