What are the guidelines for managing wheezing in a 1-year-old?

Guidelines for Managing Wheezing in 1-Year-Olds

For 1-year-olds with wheezing, initial management should include bronchodilators, with progression to inhaled corticosteroids for persistent symptoms, and specialized diagnostic testing only for those who fail to respond to standard therapy. 1

Initial Assessment and Treatment Approach

• Wheezing in 1-year-olds is common, with approximately 34% of children experiencing at least one episode before age 3 years 1
• Most episodes are mild, episodic, and easily treated, but some infants develop severe recurrent or persistent wheezing 1
• Initial treatment should include short-acting beta-2 agonists (bronchodilators) delivered via metered-dose inhaler with a spacer and face mask for symptomatic relief 1, 2
• Bronchodilator response may be variable in the first year of life but should still be attempted 1

Treatment Escalation for Persistent Symptoms

• For infants with persistent wheezing despite bronchodilator treatment, inhaled corticosteroids (ICS) are the preferred long-term control medication 1
• ICS can be considered for infants who consistently require symptomatic treatment more than 2 days per week for a period exceeding 4 weeks 1
• ICS should also be considered for infants who have had 2 exacerbations requiring systemic corticosteroids within 6 months 1
• The benefits of ICS outweigh concerns about potential risks of small, non-progressive reduction in growth velocity or other possible adverse effects 1
• ICS should be titrated to as low a dose as needed to maintain control 1

Delivery Devices and Medication Administration

• Children under 4 years of age will generally have less difficulty with a face mask and either a nebulizer or a metered-dose inhaler (MDI) with a valved holding chamber (VHC) 1
• Every child given inhaled steroids from an MDI should use a large volume spacer to enhance deposition of medication in the lungs 1
• FDA-approved long-term control medications for young children include:
  • Budesonide nebulizer solution (1-8 years of age)
  • Fluticasone dry powder inhaler (>4 years of age)
  • Montelukast (chewable tablets for 2-6 years; granules for down to 1 year old) 1

Diagnostic Evaluation for Refractory Wheezing

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

• An airway survey via flexible fiberoptic bronchoscopy should be considered to identify potential anatomic abnormalities (found in approximately 33% of cases) 1
• Bronchoalveolar lavage (BAL) may be useful to identify infectious or inflammatory causes 1
• Video-fluoroscopic swallowing studies should be considered to evaluate for aspiration, which is identified in 10-15% of infants with respiratory symptoms 1
• Empiric food avoidance or dietary changes are not recommended for infants without eczema 1

Special Considerations

• Viral respiratory infections are the most common cause of wheezing in this age group 1, 3
• For viral-induced wheezing, montelukast may be considered and can be started when symptoms of a viral cold develop 2
• Hypertonic saline (5%) with albuterol has shown benefit in reducing length of stay and admission rates in preschool children with acute wheezing episodes 4
• Breast feeding should be encouraged as it has a protective effect in relation to early life wheezing 1
• Exposure to tobacco smoke should be avoided 2

Prognostic Factors

• Most young children who wheeze with viral respiratory infections experience symptom remission by 6 years of age, possibly due to growing airway size 1
• However, two-thirds of children with frequent wheezing AND a positive asthma predictive index (family history of asthma, personal history of atopic dermatitis, or evidence of sensitization to aeroallergens) are likely to have asthma throughout childhood 1
• Increased frequency and severity of wheezing episodes in childhood are associated with recurrent wheeze into adulthood 1

Common Pitfalls to Avoid

• Overuse of nebulizers, which are expensive, time-consuming, and often inefficient compared to large volume spacer devices 1
• Failure to consider alternative diagnoses in infants with persistent symptoms, such as gastro-esophageal reflux, cystic fibrosis, and chronic lung disease of prematurity 1
• Continuing medications without evaluating their clinical benefit - treatments should be discontinued if there is no clear improvement 2
• Inadequate parent education about proper inhaler technique, medication administration, and recognition of worsening symptoms 1