What is the initial management for a pediatric patient presenting with cough, cold, and wheeze?

Initial Management of Pediatric Cough, Cold, and Wheeze

For a pediatric patient presenting with cough, cold, and wheeze, initiate a trial of short-acting inhaled bronchodilator (albuterol) via metered-dose inhaler with spacer (MDI+S), and if symptoms suggest recurrent wheezing or asthma, consider a trial of inhaled corticosteroids with close monitoring for clinical improvement. 1, 2

Critical Safety Considerations

Avoid over-the-counter cough and cold medications in children under 2 years of age due to lack of proven efficacy and potential for serious toxicity, including death. 2 Between 1969-2006, there were 54 fatalities associated with decongestants and 69 fatalities associated with antihistamines in young children. 2

• Antibiotics have no place in the management of uncomplicated asthma or viral-triggered wheeze. 1, 3
• Chest physiotherapy is NOT beneficial and should NOT be performed. 2

Initial Assessment and Diagnostic Clues

Determine if this represents asthma versus simple viral bronchiolitis by evaluating for:

• Recurrent wheeze (more than one episode) 1
• Family history of asthma or atopy 1
• Night time disturbance by wheeze or cough 1
• Symptoms precipitated by viral infections, exercise, or environmental triggers 1
• Age consideration: In children under 2 years, bronchiolitis is characterized by tachypnea, wheeze, and/or crackles following an upper respiratory illness, with 90% being cough-free by day 21. 1

Immediate Bronchodilator Management

Administer albuterol via MDI with spacer as first-line therapy:

• For children ≤2 years: 2.5 mg (or 4-8 puffs via MDI+S) every 20 minutes for up to 3 doses 4, 5
• For children >2 years: 5.0 mg (or 4-8 puffs via MDI+S) every 20 minutes for up to 3 doses 4
• MDI with spacer is preferred over nebulization as it is equally effective, may result in lower admission rates, causes fewer cardiovascular side effects, and is easier to use. 1, 2, 4, 5, 6, 7, 8

Evidence strongly supports MDI+S over nebulization:

• Meta-analysis of 15 studies (n=2057) showed significant reduction in pulmonary index score and smaller increase in heart rate with MDI+S compared to nebulization. 8
• Children treated with MDI+S had shorter ED treatment times (66 vs 103 minutes) and less vomiting (9% vs 20%). 7

When to Add Systemic Corticosteroids

Administer oral corticosteroids immediately if:

• The child fails to respond to 2 doses of albuterol within 24 hours 4
• Respiratory rate >50 breaths/minute (age <5 years) or >25 breaths/minute (age ≥5 years) 4
• The child is too breathless to talk or feed 4
• Peak expiratory flow <60% of predicted (if measurable) 1

Dosing:

• Oral prednisolone 1-2 mg/kg (maximum 60 mg) as a single dose 1, 4
• Continue daily until 2 days after control is established; no tapering needed for courses of 1-5 days 1
• If vomiting or unable to take oral medications, give IV hydrocortisone 200 mg every 6 hours (or 4 mg/kg/dose) 4

Criteria for Initiating Long-Term Controller Therapy

Consider daily inhaled corticosteroids if the child has:

• More than 3 episodes of wheezing in the past year lasting >1 day AND affecting sleep 3
• Risk factors for persistent asthma (family history of asthma/atopy, personal history of atopy) 3
• Symptoms requiring bronchodilator use more than twice weekly 3

Low-dose inhaled corticosteroids are the preferred first-line controller therapy for persistent asthma in children. 3

Supportive Care Measures

• Ensure adequate hydration to help thin secretions 2
• Administer antipyretics (acetaminophen or ibuprofen) for fever and comfort 2
• Gentle nasal suctioning may help improve breathing in children with nasal congestion 2
• Maintain oxygen saturation >92% using supplemental oxygen if needed 2, 4

Common Pitfalls to Avoid

• Do not delay systemic corticosteroids while continuing repeated doses of albuterol alone after treatment failure. 4
• Do not use asthma medications for chronic cough (>4 weeks) after acute viral bronchiolitis unless other evidence of asthma is present (recurrent wheeze and/or dyspnea). 1
• Do not routinely prescribe bronchodilators or inhaled corticosteroids to children without recurrent respiratory symptoms. 1
• Asthma in early childhood is frequently underdiagnosed, receiving labels such as chronic bronchitis or wheezy bronchitis. 3

When to Escalate Care

Admit to hospital if:

• Persistent features of severe asthma after initial treatment 4
• Peak expiratory flow <50% predicted 15-30 minutes after treatment 4
• Afternoon or evening presentation with poor response 4
• Parents unable to give appropriate treatment at home 4

Seek immediate medical care if:

• Child cannot complete sentences in one breath 4
• Pulse >110 bpm or respiratory rate >25/minute persists after treatment 4
• Child appears exhausted, drowsy, or confused 4

Follow-Up

• Review within 48 hours if managed at home to ensure improvement 2
• If cough persists beyond 4 weeks, systematic evaluation using pediatric-specific algorithms is required, including consideration of 2 weeks of antibiotics for wet/productive cough (targeting S. pneumoniae, H. influenzae, M. catarrhalis). 1
• Provide written action plan detailing when to increase bronchodilators and when to seek immediate care 4