Articles

Update in the diagnosis and management of preschool wheezing disorders

ABSTRACT
Recurrent episodes of wheezing in children aged under 6 years are common and preschool children account for the majority of all childhood hospitalizations for acute wheezing. This results in significant morbidity, has an impact on the child and family’s quality of life and places a significant demand on healthcare resources. Moreover, frequent preschool wheeze attacks are associated with an early loss in lung function which may track to adulthood. The focus of this review is to provide a structured approach to diagnosis and management of recurrent preschool wheezing, to prevent frequent attacks and minimize disease burden.
A detailed history and examination are critical to confirm wheezing as the predominant symptom, and to ensure alternative symptoms such as stridor, or chronic wet cough which may result from alternative diagnoses have been excluded. The constellation of wheezing with breathlessness, difficulty breathing and/or cough, supports a diagnosis of recurrent preschool wheeze. However, it is important to undertake some investigations to define the type of wheezing a child has and help decide optimal management.
In contrast to school-age asthma, preschool children with recurrent wheezing may not have an allergic, eosinophilic phenotype which will respond to maintenance inhaled corticosteroids (ICS). Assessment for aeroallergen sensitization and elevated blood eosinophils (>300 cells/mcl) when the child is well and in between episodes, helps to identify children more likely to improve with daily ICS. If neither of these tests are positive, ICS may be less effective, and assessments for lower airway bacterial infection may be helpful to decide whether treatment with targeted antibiotics is beneficial. There is preliminary evidence that oral or sublingual mixed bacterial lysates may also reduce symptoms and attacks in non-sensitized children, especially those who only have symptoms precipitated by upper respiratory infections.
Recurrent preschool wheeze is heterogeneous, and management to prevent attacks should be tailored for each child. We have biomarkers to identify children most likely to have steroid responsive wheezing. However, evidence-based biomarkers and treatments for children with non-allergic, non-eosinophilic recurrent wheezing remain a significant unmet need.

Received: Oct 05, 2024
Accepted: Jan 14, 2025

Table of Contents: Online first

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