Management of Reactive Airway Disease in a 1-Year-Old
For a 1-year-old with reactive airway disease, inhaled bronchodilators delivered via a face mask with either a nebulizer or metered-dose inhaler with valved holding chamber are the first-line treatment, with inhaled corticosteroids recommended for those with recurrent symptoms or exacerbations. 1
Diagnosis and Assessment
- Reactive airway disease in infants often presents with wheezing, cough, and respiratory distress, frequently triggered by viral respiratory infections 1, 2
- Assessment should focus on:
Acute Management
Mild to Moderate Symptoms
- Salbutamol (albuterol) delivered via:
- Monitor response after 15-30 minutes 1
- If improvement is seen, continue as needed every 4-6 hours 1
Severe Symptoms
- High-flow oxygen via face mask to maintain oxygen saturation >92% 1
- Nebulized salbutamol (albuterol) 5 mg or terbutaline 10 mg (half doses in very young children) 1
- Consider adding ipratropium 100 μg nebulized every 6 hours 1
- Oral prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) 1
- If not improving after 15-30 minutes:
- Continue oxygen and steroids
- Give nebulized β-agonist more frequently (up to every 30 minutes)
- Add ipratropium to nebulizer and repeat 6 hourly until improvement starts 1
Life-Threatening Features
- Immediate hospitalization with consideration for intensive care if:
- Poor respiratory effort
- Cyanosis, silent chest, or fatigue/exhaustion
- Agitation or reduced level of consciousness 1
Long-Term Management
For Infrequent Episodes
- As-needed bronchodilator therapy with albuterol via MDI+VHC or nebulizer 1, 3
- Albuterol is FDA-approved for children 2 years and older, but is commonly used in younger children 3, 4
For Recurrent Episodes
- Consider daily inhaled corticosteroids (ICS) if:
- Budesonide nebulizer solution is FDA-approved for children 1-8 years of age 1
- For children with primarily viral-triggered symptoms, consider leukotriene receptor antagonists (montelukast granules are approved for children down to 1 year old) 1, 5
Delivery Devices
- Children under 4 years generally have less difficulty with:
- Face mask with nebulizer, OR
- MDI with valved holding chamber (VHC) and face mask 1
- Proper technique is crucial for effective medication delivery 1
Special Considerations for 1-Year-Olds
- Response to bronchodilators may be variable but still worth trying 4, 6
- Approximately 52.5% of very young children show significant improvement in airway resistance after bronchodilator therapy 6
- Monitor closely for side effects, including tachycardia, which can be more pronounced with nebulized versus MDI delivery 1, 3
- Treatment is often in the form of a therapeutic trial - if no clear benefit is seen within 4-6 weeks despite proper technique and adherence, consider stopping or changing therapy 1
Follow-up Care
- Follow-up within 1 week after an acute episode 1
- Education for caregivers on:
- Monitor for symptom improvement and medication side effects 1
Cautions and Pitfalls
- Not all wheezing in infants is asthma - consider other diagnoses such as gastroesophageal reflux or anatomical abnormalities 1
- Viral respiratory infections are the most common trigger in this age group, and many children who wheeze with these infections will outgrow symptoms by age 6 1
- Avoid overuse of nebulizers when MDI with spacer can be equally effective and more efficient 1
- Inhaled corticosteroids should be titrated to the lowest effective dose to minimize potential side effects 1