What is the best management for a 4-year-old boy with a history of eczema (atopic dermatitis) presenting with cough and wheezing, who has had a similar episode in the past and was 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), which should be initiated immediately as the preferred first-line long-term controller therapy for this child with recurrent wheezing and atopic dermatitis. 1

Clinical Rationale

This 4-year-old presents with classic indicators for persistent asthma requiring long-term controller therapy:

• Recurrent wheezing episodes (current episode plus similar episode weeks ago) 2
• History of eczema (atopic dermatitis) - a major risk factor for persistent asthma 2, 1
• Wheezing apart from colds (the previous episode occurred without preceding URTI) 2
• Already maintained on inhaled medications - suggesting previous diagnosis and treatment 3

Children under 5 years with more than three wheezing episodes in the past year that lasted more than 1 day and affected sleep, combined with either physician-diagnosed atopic dermatitis OR parental history of asthma, should strongly be considered for initiation of long-term controller therapy. 2

Why Inhaled Corticosteroids Are the Answer

Inhaled corticosteroids are the preferred first-line treatment for initiating therapy in children of all ages with persistent asthma, based on superior evidence of efficacy compared to all alternatives. 2, 1

Specific Recommendations:

• Low-dose inhaled corticosteroids such as fluticasone propionate 100 mcg twice daily or budesonide nebulizer solution should be initiated 1
• Delivery method is critical: Use a metered-dose inhaler with a valved holding chamber (spacer) and face mask, as children under 4-5 years cannot coordinate standard MDI technique 1, 3
• Alternative controller options like leukotriene receptor antagonists (montelukast) are available but NOT preferred - they should only be considered if inhaled medication delivery is suboptimal due to poor technique or adherence 2, 1

Why NOT the Other Options

A. Chest X-ray - NOT indicated

• Diagnostic testing is unnecessary when clinical presentation clearly indicates asthma 2, 3
• The diagnosis is established by recurrent wheezing, eczema history, and previous response to inhaled medications 2
• Chest X-ray would only be warranted if considering alternative diagnoses like foreign body aspiration, pneumonia, or structural abnormalities 2

B. Spirometry - NOT feasible

• Children under 5 years cannot reliably perform spirometry 3
• Diagnosis in this age group relies almost entirely on clinical symptoms and history 3
• Spirometry becomes useful for assessment in children ≥5 years old 3

C. CT scan of the chest - NOT indicated

• No role in routine asthma management 2
• Would only be considered if suspecting structural abnormalities (vascular ring, tracheomalacia) or other rare conditions, which this presentation does not suggest 2

Critical Management Points

Close monitoring of response to therapy is essential, with reassessment within 4-6 weeks. 1 If clear benefit is not observed, alternative therapies or diagnoses should be considered. 4

Important Monitoring:

• Growth monitoring is essential when using inhaled corticosteroids, as dose-related growth suppression can occur 1
• Regular assessment of height and weight is recommended, though catch-up growth typically occurs 3
• Monitor for oral thrush and ensure proper inhaler technique with mouth rinsing after use 5

Common Pitfalls to Avoid:

• Do not delay controller therapy in children with clear risk factors for persistent asthma 2, 1
• Do not rely solely on short-acting beta-agonists for recurrent symptoms - this indicates need for controller therapy 3
• Do not choose leukotriene modifiers as first-line - while they are alternatives for mild persistent asthma, inhaled corticosteroids have superior evidence 2, 1