What is the best management for a 4-year-old boy with a history of eczema (atopic dermatitis) and recurrent cough and wheezing episodes, previously maintained on inhaled medications?

Management of Recurrent Wheezing in a 4-Year-Old with Eczema

The best management is D. Inhaled cortisone (inhaled corticosteroids), as this child meets criteria for initiating daily long-term controller therapy based on recurrent wheezing episodes and high-risk features (eczema/atopic dermatitis). 1

Clinical Reasoning

This child presents with classic indicators for persistent asthma requiring controller therapy:

• Recurrent wheezing episodes (current episode plus one a few weeks ago) 1
• History of atopic dermatitis (eczema), which is a major risk factor for persistent asthma in young children 1
• Wheezing independent of upper respiratory tract infections (the previous episode occurred without preceding URTI), which strongly suggests underlying asthma rather than simple viral-induced wheeze 1
• Already maintained on inhaled medications, suggesting previous diagnosis and treatment 1

Why Inhaled Corticosteroids Are Indicated

Guideline-based criteria met for initiating long-term controller therapy: 1

• Children under 5 years with recurrent wheezing AND a physician diagnosis of atopic dermatitis should strongly be considered for daily long-term control therapy 1
• The combination of eczema plus wheezing apart from colds (as occurred in this case) places this child at high risk for persistent asthma throughout childhood 1
• Inhaled corticosteroids are the preferred first-line long-term controller medication for initiating therapy in young children with persistent asthma 1, 2

Why Diagnostic Testing Is Not the Priority

Chest X-ray (Option A): Not indicated as the initial step in a child with clear clinical features of asthma and known atopic disease; diagnosis in this age group relies primarily on history, symptoms, and physical examination 1

Spirometry (Option B): Cannot be reliably performed in a 4-year-old child due to inability to achieve adequate coordination and technique 1

CT scan (Option C): Not indicated for straightforward recurrent wheezing in a child with atopic features; reserved for cases where anatomic abnormalities are suspected after failed appropriate asthma therapy 1, 3

Practical Implementation

Recommended approach: 1, 2

• Initiate low-dose inhaled corticosteroids (e.g., fluticasone propionate 100 mcg twice daily or budesonide nebulizer solution) 2
• Use metered-dose inhaler with valved holding chamber (spacer) and face mask, as children under 4-5 years cannot coordinate standard MDI technique 1, 2
• Monitor response closely within 4-6 weeks 1, 2
• If clear benefit is not observed and technique/adherence are adequate, consider alternative diagnoses 1, 2
• Once control is established and sustained for at least 3 months, attempt careful step-down in therapy 1

Important Caveats

Growth monitoring is essential when using inhaled corticosteroids, as dose-related growth suppression can occur, though effects are typically small and non-progressive 2, 4

Alternative controller options include leukotriene receptor antagonists (montelukast, FDA-approved down to 1 year) if inhaled medication delivery is suboptimal due to poor technique or adherence 1, 2

Ensure proper inhaler technique and family understanding of the difference between controller medications ("preventers") and rescue bronchodilators ("relievers") 1