What is the most appropriate next step in management for a patient with a history of eczema (atopic dermatitis) presenting with cough and wheezing following an upper respiratory tract infection (URTI)?

Management of Recurrent Wheeze and Cough in a Child with Atopic History

Given this child's history of eczema (atopic dermatitis), recurrent episodes of cough and wheeze (including one without URTI), and current post-viral symptoms, the most appropriate next step is to give an inhaled steroid (Option D) as empiric treatment for likely asthma.

Clinical Reasoning

Recognition of Atopic March and Asthma Risk

• Children with atopic dermatitis have a significantly elevated risk of developing asthma, with 34.1% becoming asthmatic, and this likelihood is related to the severity of the dermatitis 1
• The presence of eczema before age 4 is associated with development of asthma later in childhood, a phenomenon referred to as the "allergic march" 1
• This patient's presentation of recurrent wheeze and cough in the context of atopy strongly suggests asthma, particularly given the episode that occurred without URTI 1

Why Empiric Inhaled Steroid Treatment is Appropriate

• In patients with wheezing, history of allergy, and recurrent symptoms, lung medication including β-agonists and steroids have been shown to be beneficial 1
• Evaluation of a patient with allergic rhinitis or atopic dermatitis should always include assessment for asthma, with inquiry about typical symptoms such as difficulty breathing, cough, wheezing, and ability to exercise 1
• Treatment of allergic conditions in patients with concurrent asthma should be individualized, and the use of inhaled corticosteroids has been shown to reduce bronchial hyperreactivity and improve asthma control 1

Why Other Options Are Less Appropriate

Chest X-ray (Option A):

• Not indicated as first-line in this clinical scenario 1
• Chest radiography is primarily useful for diagnosing pneumonia, which requires focal signs, fever, and absence of URTI symptoms 1
• This patient's recurrent nature of symptoms and atopic history point to reactive airway disease rather than structural lung disease or infection 1

Spirometry (Option B):

• While lung function tests should be considered to assess chronic lung disease in patients with wheezing, prolonged expiration, history of smoking, and symptoms of allergy 1, spirometry may be difficult to perform reliably in young children
• Spirometry should be performed whenever asthma is suspected on follow-up visits 1, but should not delay initiation of treatment in a symptomatic child with clear clinical indicators of asthma

Bronchoscopy (Option C):

• This is an invasive procedure reserved for diagnostic uncertainty, suspected foreign body aspiration, or failure to respond to appropriate asthma therapy 1
• Not indicated as initial management in a straightforward presentation of likely asthma 1

Practical Implementation

Initial Treatment Approach

• Start with an inhaled corticosteroid as controller therapy, combined with a short-acting beta-agonist for symptom relief 2
• For children 4-11 years of age, an inhaled corticosteroid/formoterol combination can be used to reduce the risk of exacerbations 2
• Asthma action plans should be provided to help families manage symptoms at home 2

Follow-up and Monitoring

• Reassess response to therapy within 2-4 weeks 1
• If partial or no response occurs, consider spirometry to objectively assess lung function 1
• Continue to monitor for asthma symptoms on subsequent visits, particularly in children with atopic dermatitis 1

Common Pitfalls to Avoid

• Do not delay treatment while waiting for diagnostic testing in a child with clear clinical indicators of asthma 1
• Do not assume all post-viral cough is self-limited; the recurrent nature and atopic history mandate treatment 1
• Remember that up to 45% of patients with acute cough >2 weeks actually have asthma or COPD 1