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Wheeze in 1-5 year olds

Wheeze in toddlers

Between the ages of 12 months and 5 years many toddlers and young children will experience ‘wheeze’ associated with a cough and runny nose. The wheeze is triggered by a virus and the management is similar to how asthma is treated. This involves giving ventolin given via a spacer device and mask. Occasionally some toddlers will require preventative medication. Hospitalisation is sometimes needed if oxygen is required. Infants under 12 months who wheeze do not respond to ventolin. This is termed bronchiolitis. Antibiotics have no role in managing viral induced wheeze.

What causes the wheeze ?

A simple cold virus, will interact with the smaller airways of toddlers, resulting in inflammation. This leads to the formation of tiny bubbles. These bubbles burst and reform, resulting in wheeze, much like the squeezing of a wet sponge. If there is a large amount of inflammation (similar to a wet sponge), there will be increased work of breathing. This condition can occurs in up to 30% of children.

Is this Asthma?

Asthma is similar, and many health professionals will call this asthma. However the main difference is that those children with genuine asthma will cough and wheeze when exposed to non viral triggers. These include allergies, (pollens, pet hair, dust mite), exercise, and changes in weather. True asthma is more common in those children who have other allergies such as eczema, or allergic rhinitis (hayfever). Although not strictly asthma, an asthma action plan is often required for early childhood centres such as daycare and kindergarten.

How to treat wheeze in toddlers

Wheeze in young children

Treatment involves opening the airways with ventolin which is given by a mask and spacer device (see pic). The technique is important to ensure a tight seal around the face. This sometimes requires a firm hold which can be frustrating for parents when dealing with a fractious toddler. See Royal Childrens Asthma Videos for some tips on how to correctly use the mask and spacer.  The dose of ventolin tends to be between 4 – 6 puffs. Each puff delivered separately with 3-5 breaths between each puff. Frequency and amount of ventolin given depends on the severity and is indicated in the table below.

Assessing wheeze and cough

The toddler or child will start coughing when suffering from a cold. The cough will sound slightly moist and initially breathing will be unaffected. However in some instances there will be shortness of breath. This is assessed by carefully watching the breathing. Assess the effort involved in breathing and use exercise as an analogy. So a mild increase in chest movement is similar to someone walking, moderate is how someone’s breathing looks when jogging, and severe is what someone looks like who has just been sprinting. The table below summarises this. 

How to assess and manage wheeze
Severity Assessment of wheezeTreatment – using ventolin administered by maskOngoing treatment
MildSimilar to walking – your child will be comfortable, but there is slight increase in rate of breathing and effort. Talking is still easy without pauses for breaths. Give ventolin, 4 puffs, every 3-5 hours depending on response and whether there is improvement or deterioationAs the wheeze and cough disappears the ventolin use can be weaned. If still slight cough, then continue two puffs of ventolin twice per day
ModerateSimilar to Jogging – your child will still be comfortable, but the chest is moving more than usual and talking requires pauses for breaths. Give ventolin 6 puffs initially every 1-2 hours. If improvement noted move to mild treatment. If deterioation then move to severe treatment and seek urgent medical helpContine to use ventolin frequently. If there is limited response sometimes prednisolone is required to help with the inflammation. Seek medical advice if treatment appears to be not working.
SevereSimilar to Running – your child is clearly short of breath, talking is difficult and there is considerable effort with each breath.Give 6 puffs of ventolin every 20minutes and call an ambulance.Severe attacks that result in hospitalisation often require preventative treatments. These are safe and effective and lessen the severity and amount of medication required.

What preventatives are useful ?

  • Flixotide – This is an inhaled mild steroid to be used with a spacer. Side effects are negligible when used as directed. It can take a week or two to work.
  • Singulair – This chewable tablet can be given to toddlers over the age of two years. Unfortunately there is a rare but definite association with behaviour problems in some children and currently has a warning attached. It works to block some of the inflammatory chemicals released by the airways in response to the virus. It is not a steroid.  Its onset of action is quick so it can be used at the first sign of a cold.   In some children who get lots of episodes during the winter months, singulair can be given daily.  This will prevent significant coughing and wheezing.

Some Facts about wheezy toddlers.

  • If your child has wheezing in response to changes in temperature, or humidity, allergens such as dust mite, and exercise, this is more typical of childhood asthma.
  • Influenza A is a common trigger for particularly severe episodes, so annual vaccination is strongly recommended.
  • Ventolin syrup has no effect on wheezy toddlers.
  • Antibiotics are of no benefit in wheezy respiratory illnesses
  • There is currently very little evidence for oral steroids for typical mild viral induced wheeze.
  • Beware of alternative treatments and their claims. There is no evidence that wheat and diary have any role in viral induced wheeze.
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