What is the initial treatment for a 12-month-old patient with wheezing, considering potential allergies or eczema?

Initial Treatment for Wheezing in a 12-Month-Old

For a 12-month-old infant with wheezing, administer salbutamol (albuterol) 2.5 mg via nebulizer or 4-8 puffs via metered-dose inhaler (MDI) with large volume spacer as first-line therapy for acute symptom relief. 1

Delivery Method Selection

• MDI with large volume spacer is the preferred delivery device and is equally effective to nebulization, potentially resulting in lower admission rates with fewer cardiovascular side effects. 1, 2
• If using nebulizer, administer salbutamol 2.5 mg via nebulizer every 20 minutes for up to 3 doses in the first hour if needed. 1
• The spacer device is easier to use and better accepted by children compared to nebulization. 3

When to Escalate Treatment

If the infant shows signs of severe respiratory compromise, immediately escalate care:

• Administer high-flow oxygen via face mask to maintain oxygen saturation >92% if hypoxemia is present. 1, 2
• Add ipratropium 100 mcg to nebulizer if initial beta-agonist treatment fails, as the combination reduces hospitalizations in severe exacerbations. 1, 2
• Give oral prednisolone 1-2 mg/kg (maximum 60 mg) immediately as a single dose for severe exacerbations requiring emergency treatment. 1, 2

Critical Assessment Points

Recognize features requiring immediate aggressive treatment:

• Too breathless to feed 1, 2
• Respiratory rate >50 breaths/minute 1, 2
• Pulse >140 beats/minute 1, 2
• Oxygen saturation <92% 1, 2
• Poor respiratory effort, cyanosis, or altered consciousness 1, 2

Important Clinical Context

• Most infants with wheezing have transient conditions associated with viral respiratory infections and do not have increased risks of asthma later in life. 4
• There is limited evidence for overall beneficial clinical effect of nebulized beta-agonists in all infants with acute wheezing, though some may respond. 4
• However, in infants with allergies or eczema (positive modified asthma predictive index), early recognition and treatment may be important, as these children are at increased risk of developing persistent asthma. 5

Common Pitfalls to Avoid

• Do not underestimate severity in very young children—assessment can be difficult, and any concerning features should prompt aggressive treatment. 1
• Ensure proper inhaler technique education to caregivers—most young children cannot achieve coordination for unmodified MDI use and require spacer devices. 1, 2
• Do not delay systemic corticosteroids while giving repeated albuterol doses alone if the infant shows signs of severe exacerbation. 2

Reassessment and Follow-Up

• Reassess response 15-30 minutes after starting treatment to evaluate effectiveness. 2, 1
• Relief treatment can be repeated 2-4 hours at home, but failure to respond or early deterioration requires immediate medical assessment. 2
• Provide written action plan for parents detailing when to increase bronchodilators and when to seek immediate care. 1, 2

When to Seek Emergency Care

Seek immediate medical attention if:

• Infant remains too breathless to feed after initial treatment 1
• Persistent tachypnea (>50 breaths/minute) or tachycardia (>140 beats/minute) 1
• Oxygen saturation remains <92% 1
• Exhaustion, drowsiness, or confusion develops 2