Treatment of pre-school children with wheeze questioned
Wheeze in pre-school children can be a challenging clinical problem to diagnose and treat. A provocative paper, an evidence-based clinical review, challenges some of the conventional wisdom.
The review covered a combined study population of around 2,000 children. It highlights the fact that such children typically develop episodic symptoms, often triggered by viral infections, and are generally well between attacks.
It suggests the term ‘pre-school viral wheeze' (PVW) to distinguish it from asthma in older children. PVW is indistinguishable from atopic asthma in this age group, although atopic children will have symptoms continuing into later childhood.
Pharmacotherapeutics are examined. I have always doubted the effectiveness of ß2 agonists in children under two; this review supports this view and goes further, suggesting that there is little evidence that these drugs work before the age of five.
Anticholinergics, such as ipratropium, are also not shown to be effective, although some evidence is cited for an anticholingeric and ß2 agonist combination to reduce wheezy symptoms in children over two.
No evidence is found to support the use of oral steroids in acute attacks. It is worthwhile to note that the review confines itself to PVW, and excludes bronchiolitis. Inhaled steroids have no role in routine prophylaxis, although they can shorten an attack of PVW if started at a moderately high dose at the first sign of symptoms. Regular monteleukast is also potentially useful, with some evidence supporting its use to reduce the number and severity of exacerbations.
On the basis of this review a two-year-old presenting with an exacerbation of recurrent PVW should be given inhaled steroids and possibly a combination of ipratropium and salbutamol. Long-term treatment with monteleukast should be considered.
There is no evidence for the treatment of patients younger than this, although my view is that it would take a courageous doctor not to prescribe bronchodilators and steroids to an ill child in this group.
It's funny how medical terms come and go; some years ago we used the term ‘wheezy bronchitis', which was discredited for ‘asthma', and which now seems to be re-invented as ‘PVW'.
Panickar JR, Grigg J. Controversies in the management of preschool viral wheeze. Paediatr Respir Rev 2006;7:293-8Reviewer
Dr Peter Saul
GP, Wrexham and hospital practitioner in paediatrics (asthma and allergy)