Wheeze in preschool children

A distressed wheezing childA very common condition, affecting 25% of infants before the age of 18 months, and one which we will see a lot of over the forthcoming months.

This helpful BMJ Review summarises the evidence on the management of wheeze in this preschool population (BMJ 2914;348:g15). Importantly, this doesn’t cover bronchiolitis, another condition common at this time of year!


The European Respiratory Task Force has proposed a new classification of preschool children with wheeze:

  • Episodic viral wheezers (EVW) – wheeze only with viral upper respiratory tract infections (URTIs).
  • Multi-trigger wheezers (MTW) – wheeze with URTIs, but also with other triggers, e.g. exercise, allergen exposure and smoke.

This is useful as these children are phenotypically different and, as we’ll see, are managed differently too.

Is it asthma?

This is what every parent wants to know! Those with MTW are more likely to develop asthma, but the evidence clearly shows no benefit of inhaled corticosteroid (ICS) use in reducing future risk of asthma.

Episodic viral wheeze: management options

Conservative management

  • Think about environmental factors particularly parental smoking.
  • Consider whether drug treatment is needed at all especially, if no respiratory distress.

Salbutamol/ipratropium PRN (with spacer) is first-line drug treatment.

  • Ensure parents are using them properly.

Intermittent montelukast/ICS

  • If inadequate symptomatic response, started on first day of a cold and stopped when symptoms resolve.

Combination of both intermittent montelukast and ICS

  • In most severe cases.

So what’s the evidence for these drugs?

Bronchodilators (Cochrane 2002, CD002873)

  • No clear benefits in pre-schoolers with viral wheeze, no harms demonstrated either.
  • Therefore, use only if child benefits and use with a spacer.

Maintenance ICS (Cochrane 2002, CD001107)

  • No reduction in hospital admissions or need for oral steroids.
  • No role for preventative ICS.

Episodic ICS (NEJM 2009;360:339)

  • High dose ICS offered some benefits but harms (reductions in growth and weight gain) thought to outweigh these benefits.
  • High dose ICS use inappropriate in primary care.

Montelukast (BMJ 2014;348:g15)

  • A small RCT showed intermittent therapy offers benefits with less unscheduled appointments and missed childcare days, although not confirmed by a subsequent larger RCT.

Oral steroids (NEJM 2009;360:329)

  • RCT of steroids v’s placebo showed no benefit in patients presenting to UK hospitals, with community-based studies demonstrating similar findings (Lancet 2003;362:
  • For children with viral wheeze and no history of asthma, don’t prescribe prednisolone in community or hospital

Back to the BMJ Review and MTW……

Multi-trigger wheeze: management options

Here there’s a lack of evidence of the best treatment. The review offers a pragmatic approach, bearing in mind this group are more likely to develop asthma later in life:

  • Inhaled bronchodilators PRN basis are first-line.
  • If child has wheeze/cough most days that responds to bronchodilators, consider preventative treatment:
    • Trial of ICS/montelukast for 4-8w.
    • Only continue if symptoms improve on treatment and step-down to lowest dose possible.
    • If no improvement at end of trial and symptoms problematic, consider referral.

1 Response

  1. Irene Cotter
    Dear Dr. Lettis I am a GP in Cyprus and I have found your articles very useful. I saw an excellent presentation on common childhood rashes in general practice but could not download it. Would it be possible to have access to this article?

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