HNY Policy and Pathway Repository - York

Presence of wheezing in pre-school children aged 1-5 years.

Acute wheeze in pre-school children is predominantly cause by viral respiratory infections, including rhinovirus and respiratory syncytial virus (RSV).

Paediatric Normal Values (adapted from APLS)
Age	Resp Rate	Heart Rate	Systolic BP
Neonate <4w	40-6	120-160	>60
Infant <1 y	30-40	110-160	70-90
Toddler 1-2 yrs	25-35	100-150	75-95
2-5 yrs	25-30	95-140	85-100

• SpO2 <92%, cyanosis
• Bradycardia <100 bpm
• Apnoea
• Marked sternal recession
• Persistent or worsening shortness of breath
• Too breathless to feed or speak
• Poor air entry
• Agitation, confusion
   

Low Threshold for Acute Referral

• Extreme low birth weight
• Prolonged NICU/SCBU
• Congenital heart disease
• Significant co-morbidity
• Reduced feeding <50%
• Previous severe episode
• Attack in late afternoon, at night or early in the morning
• Psychosocial stressors
• Recent hospital admission
• Already taking steroids
• Food allergy

General Points

• Lower respiratory tract illnesses with wheeze occur in around a third of all pre-school children aged 1-5 years
• Acute wheeze is one of the most common reasons for emergency department attendance and hospital admission in children
• Management strategies are extrapolated from school-aged children with asthma
• In contrast with school-aged children presenting with wheeze, most pre-school children are non-atopic (75%)
• A small subgroup with pre-school wheeze with sensitization to aero-allergens may response to maintenance inhaled steroids to prevent attacks.
   

Assessment Symptoms

• Wheeze
• Cough
• Breathlessness
• Chest Tightness
   

Useful Questions

• Does your child have noisy breathing?
• Does the noise sound like a high-pitched whistle? (likely wheeze)
• Do they have noisy breathing or breathlessness only with colds (likely viral induced wheeze)
• Does the noise sound like a snore or rattle in the chest? (likely upper airways noise and not wheeze)
• Is there associated difficulty in breathing and/or cough? (likely wheeze)
• Do they cough, choke or gag when eating or drinking (consider aspiration)
• If they cough, does it sound chesty? (consider undiagnosed cystic fibrosis)

Most children with viral induced wheeze will stop wheezing as they get older, and not go on to develop asthma

Use code ‘suspected asthma’, asthma diagnosis should be confirmed when the child can undergo objective testing
 

Risk Factors for Persistent Asthma

• Earlier the onset of wheeze, the better the prognosis
• Frequent or severe episodes
• Atopy, e.g. eczema or rhinitis
• Family history of atopy, the strongest association is with maternal atopy
• Exposure to smoking
• Interval symptoms, or non-infective triggers for wheeze
   

Clinical Decision Aid

☐            Yes	Does child have interval symptoms when they do not have viral infections?	☐            No
☐            Yes	Are the exacerbations severe and /or frequency	☐            No
☐            Yes	Are any of the following present: Atopy (personal or first-degree relative) Eosinophilic inflammation (serum, FeNO) Sensitisation (IgE, RAST, skin prick test)	☐            No
More like preschool asthma		More like preschool episodic wheeze

 

Differential Diagnoses

It is important to differentiate between viral induced wheeze, other causes of wheeze and asthma.

• Pneumonia: pyrexia >38.5°C, productive cough, asymmetry on auscultation
• Croup: inspiratory stridor, barking cough • Foreign body: localized wheeze and reduced air entry
• Epiglottitis: dysphagia, drooling
• Undiagnosed cystic fibrosis
• GORD: vomiting, history of reflux as an infant
• Anaphylaxis
   

Features suggesting alternative diagnosis

• Symptoms present since birth
• Persistent wet or productive cough
• Failure to thrive
• Excessive vomiting
   

Acute Management

Acute asthma drug doses
Treatment	Age (years)	Dose (mg)
Salbutamol (nebs)	>5	2.5
Ipratropium bromide (nebs)	All ages	0.25 (250 micrograms)

Inhalation Device

• For children <5y: pMDI + spacer with a mask is the first choice inhalation device
• Patients should be given adequate training in the use of the inhalation device
• Clean spacers once a month with mild detergent and allow to air dry. Replace every 6- 12months.

Bronchodilators

• In the absence of severe and life-threatening features, SABA should be initiated using a metered dose inhaler (MDI) and spacer (with mask)
• Nebulised SABA and ipratropium bromide with oxygen should be initiated in children with hypoxia

Prednisolone

• Most acute attacks of wheezing in pre-school children are in non-allergic children, and are primarily driven by respiratory infections, therefore, these children are very unlikely to have elevated lower airway eosinophils which would response to corticosteroids during acute episodes
• Oral corticosteroids are often overused, and should only be considered if this has been recommended by secondary care.

Inhaled Indicators for Nebulised Bronchodilators

• SpO2 <94%
• Unable to use inhaler and spacer
• Severe respiratory distress
   

Chronic Management

Intermittent Reliever Therapy

• Children should be prescribed a short-acting bronchodilator to relieve symptoms
• For many children, occasional use of reliever is all that’s required

Short acting beta2 agonists (SABAs)

Salbutamol

• Child, by aerosol inhalation: 100–200 micrograms (1–2 puffs); for persistent symptoms up to 4 times daily
   

Regular Preventer Therapy

Inhaled Corticosteroids

If there is a history of atopy or they present with severe symptoms then consider a trial of maintenance therapy. However, this is not always effective.

Beclometasone Dipropionate

Clenil Modulite: aerosol inhalation
50 mcg/dose and 100 mcg/dose; are licensed for use in children

Step 1: Trial ICS with beclomethasone dipropionate equivalent 200 micrograms twice daily for 6- 12 weeks then review. Ensure advice has been provided on correct technique and appropriate spacer device given.

Step 2: Stop ICS. If symptoms have not improved, check adherence and recheck technique and device. If symptoms have improved, wait and see if they return after stopping ICS

Step 3: If symptoms has improved on ICS and return, restart ICS at lowest effective dose

Leukotriene receptor antagonists (LTRAs)

Montelukast:
Consider if exercise induced asthma is a specific problem in a patient otherwise well controlled. Trial treatment for 4 weeks, if no benefit then discontinue. Risk of GI upset, and more rarely problems with sleep and behaviour

• 6m-5y: 4mg once daily in the evening, as a chewable tablet or granules

Indications for referral

• Two or more courses of systemic corticosteroids in the previous 12 months (NOTE: oral corticosteroid in this age group should not be standard practice)
• Control not achieved on Step 4
• Children under 2y
• Diagnosis unclear
   

Information to include in referral letter

• Exacerbation history: number of exacerbations in past 12 months
• Any courses of oral steroids in past 12 months
• History of atopy: include any known triggers
• Current medication

Patient information leaflets/ PDAs

https://www.asthma.org.uk/advice/inhaler-videos/facemask-child/ 

Pre-school wheeze pathway leaflet

Pre-school wheeze patient information

Pre-school Wheeze stepwise management

Acute asthma - traffic light system

 

References

• Makhecha S. et al. Diagnosis and management of wheeze in pre-school children. The Pharm Journ. Mar 2021
• Bush A et al. Managing wheeze in preschool children. BMJ 2014; g15-g15. doi:10.1136/bmj.g15
• Saglanu S. et al. Advances in the aetiology, management and prevention of acute asthma attacks in children. The Lancet Child & Adolescent Health 2019; 354-64. doi:10.1016/s2352-4642(19)30025-2
• Elenius V, et al. Lung function testing and inflammation markers for wheezing preschool children: A systematic review for the EAACI Clinical Practical Recommendations on Diagnostics of Preschool Wheeze. Pediatr Allergy Immunol doi:10.1111/pai.13418