Wheezing is very common in infancy and early childhood. Approximately 50% of children will wheeze before age 6, and of these, approximately one-third will develop persistent asthma. However, this also means that two-thirds of infants and young children who wheeze will not develop persistent asthma and so may wheeze for other reasons.

 

The current thinking is that we may need to begin treatment early in order to prevent the changes that lead to lung function decline; studies are underway to explore this more. Health care providers make careful decisions to try to identify those infants and young children who are at risk for becoming persistent wheezers and get them into aggressive treatment programs as early as possible.

 

When infants and young children present with frequent symptoms and have positive risk factors, they may need to start on long-term controller medicines. Frequent symptoms may look like:

 

Mant parents take their child to a health care provider because the child has a cough that will not go away. In fact parents often readily volunteer information about cough, perhaps because it seems more important or because it’s what keeps them awake. In turn, a health care provider will need to ask specifically about wheeze to get the full picture. The wheeze may well not be present when the child is seen. And they will ask about triggers as well. Less medication may be needed if triggers can be reduced or avoided.

 

If a child is old enough (usually 6-7 years old) the health care provider may recommend doing spirometry (pulmonary function test) to help determine whether the child has asthma. If spirometry is not available, PEF monitoring can be used as an alternative.

 

Children may require some creative teaching to show them how to blow into the PEF meter. Every child knows how to blow out candles on a birthday cake: a deep breath in and rapid forced breath out, just what’s needed for a peak flow meter. A few candles stuck in florist foam (you can even decorate it like a cake) may be just the way to teach good PEF technique.

 

In children it’s also important to know when not to use a PEF meter. Below age six, it’s not easy to teach PEF technique. Between ages three and six, it’s rarely advisable to use a PEF meter because the results are variable and not reliable.

 

For some children it will be more important to teach inhaler technique than PEF technique if the child can’t master both correctly, leaving the PEF meter aside for the time being.

 

In the absence of objective data such as spirometry, diagnosis may need to be “confirmed” by response to treatment. So, in a child under five suspected of having asthma, some health care providers use bronchodilators and watch over a few days for an improvement in symptoms.

 

Another approach is to give a 3-10 day course of oral corticosteroids in order to improve symptoms. The appropriate dose will vary with the size and age of the child.

 

One reason may be that health care providers have often been reluctant to label children as having asthma. In one sense, disease labels are unimportant, but the wrong label often leads to the wrong treatment. The diagnosis of “bronchitis” is more likely to result in the prescribing of antibiotics than bronchodilators. A parent is unlikely to call the doctor or 911 for an attack of what they think is “bronchitis.” Parents may not be aware of the potential dangers of poorly controlled asthma. Acute bronchitis is unlikely to occur several times a year in persons with normal lung function. Patients consulting for cough, wheeze or breathlessness more than twice in one year should have asthma considered as a diagnosis and have other severe conditions ruled out as well.