Management of Wheezing in a 22-Month-Old Child
Immediately administer nebulized salbutamol 2.5 mg (half the standard 5 mg dose for very young children) via oxygen-driven nebulizer, and assess severity to determine if systemic corticosteroids are needed. 1, 2
Initial Severity Assessment
First, rapidly determine if this is acute severe asthma requiring aggressive treatment by looking for these specific features in your 22-month-old: 1
- Too breathless to feed (critical in infants/toddlers) 1, 2
- Respiratory rate >50 breaths/minute 1, 2
- Heart rate >140 beats/minute 1, 2
- Oxygen saturation <92% 1, 2
Life-threatening features requiring immediate hospital transfer include: 1
- Silent chest, cyanosis, or exhaustion 1
- Poor respiratory effort 1
- Altered consciousness or agitation 1
Immediate Treatment Based on Severity
For Mild-Moderate Wheezing (No Severe Features)
- Nebulized salbutamol 2.5 mg every 4-6 hours initially 4, 2
- Alternative delivery: 4-8 puffs via MDI with large volume spacer (equally effective, potentially fewer side effects) 2
- Reassess response at 15-30 minutes after initial dose 1, 2
Do NOT give systemic steroids if the child responds well to bronchodilators and has no severe features 5
For Acute Severe Wheezing (Any Severe Features Present)
Immediate combined therapy: 1, 5
Nebulized salbutamol 2.5 mg (half dose for very young children) via oxygen-driven nebulizer 1, 4
Oral prednisolone 1-2 mg/kg immediately (maximum 40 mg; for a 22-month-old weighing ~12 kg, give 12-24 mg) 1, 5, 4
Add ipratropium 100 mcg to nebulizer if initial bronchodilator fails 1, 2
Escalation Protocol if Not Improving After 15-30 Minutes
Continue oxygen and steroids, then: 1
- Increase nebulized β-agonist frequency to every 30 minutes 1
- Add ipratropium 100 mcg to nebulizer, repeat 6-hourly 1
- Consider hospital transfer if deterioration continues 1, 2
For life-threatening features: 1
- Give IV hydrocortisone 1
- Administer IV aminophylline 5 mg/kg over 20 minutes, followed by 1 mg/kg/hour infusion (omit loading dose if already on oral theophyllines) 1, 4
Critical Pitfalls to Avoid
Assessment challenges in very young children: 1
- Assessment can be extremely difficult at 22 months of age 1
- Do not underestimate severity—any concerning features should prompt aggressive treatment 2
- The inability to feed is the most reliable severe feature in this age group 1, 2
Delivery device errors: 1, 4, 2
- Most children under 2 years cannot use unmodified MDI 1
- Always use large volume spacer with MDI 1, 2
- Nebulizers are often overused when spacers would suffice 1
Steroid timing errors: 5
- Give the first dose immediately upon recognizing severe exacerbation 5
- Do not delay steroids while giving repeated albuterol alone 2
Outpatient Management for Responders
If child improves with initial treatment: 5, 2
- Continue salbutamol 2.5 mg nebulized every 4-6 hours as needed 4
- No systemic steroids needed if mild exacerbation that responds quickly 5
- Provide written action plan to parents detailing when to increase bronchodilators and when to seek care 5, 2
- Prednisolone 1-2 mg/kg daily for 3-5 days (no taper needed for courses <10 days) 5, 4
- Maximum 40 mg daily 5, 4
- Reassess within 48 hours to ensure objective improvement 5, 2
- Schedule primary care follow-up within 1 week 1, 5
Hospital Admission Criteria
- Failure to respond to initial bronchodilator and oral steroid therapy 1
- Any life-threatening features present 1
- Persistent severe features after initial treatment 1
- Parents unable to administer treatment reliably at home 2
Phenotype Considerations for This Age
At 22 months, this child likely has episodic (viral) wheeze rather than established asthma, as most wheezing at this age is transient and virus-triggered 6, 7, 8. However, treatment approach is identical regardless of phenotype during acute episodes 8. Consider maintenance therapy only if multiple episodes occur, but this is a separate decision from acute management 8.