The Wheezing Child
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Description
Wheezing is a common presentation in young children.
Key points:
- Determining the cause of wheeze in young children can be difficult and sometimes is determined only
following a trial of treatment. - Parents’ description of wheeze can be inaccurate and often needs elaboration or confirmation with
impersonation or video recordings. - Asthma is very common but other causes are also common and worth considering in the event of poor
efficacy of asthma treatment. - A diagnosis of protracted bacterial bronchitis should be considered for children with >4 weeks of
continuous wet cough.
Presentation of the wheezing child
|
Condition |
Estimated incidence in children
|
Clinical signs |
Investigation |
Expected clinical course
|
Management |
|
Viral wheeze Viral LRTI Bronchiolitis |
Very common, especially in the first 2 years of life. 50% of children will have at least one wheezing episode |
Wheeze associated with respiratory tract infections. May be singular or recurrent. Crackles and rhonchi on auscultation |
No specific investigations. Nasal samples sent for virology usually do not change clinical management but isolation of RSV in infants is highly suggestive of bronchiolitis |
60% will outgrow wheeze by 6 years. A further 15% acquire wheezing after 6 years. After 7–8 years, only 1 in 5 will outgrow it |
Trial salbutamol if >1 year of age and continue only if effective. Supportive care involving monitoring adequate fluid intake (>50% of usual intake) and for signs of increasing respiratory distress |
|
Asthma |
15–20 % of the paediatric population |
Wheeze on a regular basis. Some will have persistent/interval symptoms between episodes of viral wheeze (cough and/or wheeze at night or with exercise) |
Spirometry with bronchodilator response may be possible in children ≥5 years of age in experienced laboratories |
Usually expected to be lifelong but clinical courses can vary widely between individuals
|
Exacerbations: Regular salbutamol (as per asthma guidelines) and consider oral prednisolone for up to 5 days. Regular preventer usually indicated |
|
Airway malacia (airways floppiness): either tracheomalacia or bronchomalacia |
1 in 2100 |
Present soon after the neonatal period stridor, cough, and rattling; Children are usually well and often labelled as ‘happy wheezers’ |
Bronchoscopy usually diagnostic but not necessary in most cases
|
Resolves by age 2 years. Secondary PBB can occur, presumably from poor cough clearance |
Treatment is rarely required. If there are worsening symptoms or failure to thrive, specialist referral is indicated |
|
Protracted bacterial bronchitis (PBB) |
Unknown
|
Chronic wet cough (typically >4 weeks). Concurrent wheeze and/or rattly breathing is common |
Bronchoscopy may assist diagnosis, but usually unnecessary. Radiological findings usually normal or nonspecific |
Majority resolve with 1–2 courses of antibiotics |
2–6 week course of antibiotics: commonly amoxicillin/clavulanic acid (approximately 20 mg/kg/dose twice daily) |