What is the recommended management for early wheezers in infancy?

Management of Early Wheezing in Infancy

For infants with frequent wheezing episodes, inhaled corticosteroids are the preferred first-line treatment, with leukotriene receptor antagonists as an alternative option. 1 Early recognition and appropriate management of wheezing in infancy is crucial as up to 80% of children with asthma develop symptoms before their fifth birthday.

Diagnostic Considerations

Wheezing in infancy is common but challenging to diagnose properly. Important considerations include:

• Distinguishing between different phenotypes:

  • Viral-induced wheezing (most common cause in infants)
  • Early-onset asthma
  • Structural airway abnormalities

• Risk factors for persistent asthma include:

  • Parental history of asthma
  • Physician-diagnosed atopic dermatitis
  • Allergic rhinitis
  • Peripheral blood eosinophilia (>4%)
  • Wheezing apart from colds 1

• Differential diagnoses to consider:

  • Cystic fibrosis
  • Vascular ring
  • Tracheomalacia
  • Primary immunodeficiency
  • Congenital heart disease
  • Foreign body aspiration 1

Treatment Algorithm

1. Initial Management for Episodic Wheezing

• First-line: Short-acting β2-agonist (SABA) as needed
  • Salbutamol/albuterol via nebulizer (0.15 mg/kg) or metered-dose inhaler with spacer 2
  • For acute episodes requiring more frequent treatment (>every 4 hours), consider short course of oral corticosteroids

2. For Persistent or Recurrent Wheezing

Initiate long-term control therapy when:

• More than 3 episodes of wheezing in the past year lasting >1 day and affecting sleep, especially with risk factors for persistent asthma
• Requiring symptomatic treatment more than twice weekly
• Severe exacerbations less than 6 weeks apart 1

Treatment options:

1. Preferred treatment: Inhaled corticosteroids (ICS) 1, 2

   • Dosing: Start with low dose appropriate for age
   • For severe exacerbations: Prednisolone 1-2 mg/kg (maximum 40 mg) as a single dose 2, 3

2. Alternative treatments (if ICS not suitable):

   • Leukotriene receptor antagonist (montelukast) 1, 4
     • For ages 6-23 months: 4 mg oral granules once daily in the evening
     • For ages 2-5 years: 4 mg chewable tablet or oral granules once daily
   • Cromolyn via nebulizer 1

3. For Treatment-Resistant Persistent Wheezing

For infants with persistent wheezing despite standard treatment with bronchodilators and inhaled corticosteroids, consider:

1. Airway survey via flexible fiberoptic bronchoscopy
2. Bronchoalveolar lavage (BAL)
3. Video-fluoroscopic swallowing studies 1

Treatment Efficacy Evidence

• Regular inhaled corticosteroids have shown superior efficacy compared to as-needed treatment in preschool children with frequent wheezing, with a higher percentage of symptom-free days (69.6% vs 61.0%) 5

• In infants with atopic tendency and persistent wheezing, fluticasone treatment (150 μg twice daily) significantly improved mean daily symptom scores and symptom-free days compared to placebo 6

• High-dose inhaled beclomethasone started early at the first signs of upper respiratory tract infection has shown promise in reducing recurrent wheezing episodes in infants 7

• However, prophylactic high-dose inhaled corticosteroids after RSV infection did not significantly reduce recurrent wheezing in previously healthy infants 8

Monitoring and Follow-up

• Assess treatment response using:

  • Frequency of wheezing episodes
  • Sleep disturbance
  • Activity limitations
  • Need for rescue medications
  • Days missed from daycare/school 2

• Consider tapering treatment after a period of stability, as the natural history of preschool wheeze often involves improvement over time 9

Important Caveats

1. Avoid overtreatment: Not all wheezing in infancy progresses to asthma; many cases resolve spontaneously by school age 1

2. Proper delivery technique: Ensure appropriate delivery device for age (nebulizer or MDI with spacer and mask for infants)

3. Growth monitoring: Monitor growth in infants on long-term inhaled corticosteroids due to potential effects on growth velocity 2

4. Avoid empiric food avoidance: For infants without eczema but with persistent wheezing, empiric food avoidance or dietary changes are not recommended 1

5. Treatment limitations: Currently available therapies may control symptoms but do not appear to modify the long-term outcome of preschool wheeze 9