WHEEZING IN INFANTS

Magdalena Sidhartani
 Wheeze

A continous high – pitched

sound, with “musical”
quality, emitting from the
chest during expiration

and PLP, et al Eur Respir J 2008; 32: 1096-110.

 Wheezy Infant

• Why?
• Small airway caliber & lung
compliance
• Resistance is inversely
• Susceptible to airway
collapse
related to the radius of tube
to the 4th power • Increased resistance
• Marginal narrowing  flow
limitation  wheeze • Subsequent wheezing
• Differences in tracheal
cartilage composition & airway
smooth muscle tone
Prakash M, Johnny JC. J Pharm Bioall Sci
2015;7:S55-8
 Diagnostic category Cause
Anatomic Extrinsic to airway
Wheezing Lymphadenopathy
Mechanism Tumor
Diaphragmatic hernia
Vascular ring/aberrant vessel
Tracheomalacia
Foreign body
Endobronchial tuberculosis
Vocal cord dysfunction
BPD
CHF
Congenital lobar emphysema

Inflammatory/infectious Asthma
Bronchiolitis
RSV
Influenza A and B
Adenovirus
Bronchitis
Pneumonia
Mycoplasma pneumoniae, Chlamydia
pneumoniae
Aspiration pneumonia, Bronchiectasis

Genetic/metabolic Alpha 1 antitrypsin deficiency

Pulmonary hemosiderosis
Cystic fibrosis
Immotile cilia syndrome
Kartagener syndrome
Metabolic disturbance
Episodic wheeze

The most common viral triggers

include rhinovirus, respiratory
syncytial virus (RSV),
coronavirus, human
metapneumovirus,
parainfluenzavirus, and
adenovirus
 Recurrent wheeze
Different hypotheses :
• Viral infections  wheezing, mainly in predisposed
children when exposed at critical age
• Intermittent virus induced wheezing  persistent
wheezing in high risk,susceptible child
Multi trigger wheeze
Presipitant :
Viral
infections

Passive
smoking

Allergens

Exercise
 CHARACTERISTICS OF EPISODIC VIRAL WHEEZE AND OF MULTIPLE TRIGGER WHEEZE
Episodic viral wheeze Multiple trigger wheeze

Definition Wheezing during discrete time Wheezing that shows discrete

periods, often in association with exacerbations but also symptoms
clinical evidence of a viral cold between episodes

Triggers Viral infections Viral infections,tobacco smoke,

allergen exposure, mist exposure,
crying and exercise
Possible underlying factors Preexistent impaired lung Eosinophilic inflammation?
function,tobacco smoke
exposure,prematurity, and atopy

Continuing treatment with ICS Little or no benefit Significant fewer days with symptoms

Treatment with montelukast Moderate benefit Moderate reduction in exacerbations

Long – term outcome Declines over time (< 6 yrs) may May continue into adulthood as
continue into school age as asthma
episodic viral wheeze & may
change into multiple trigger
wheeze
Brand PLP, European Respiratory Journal.2008.
When is a wheeze not a wheeze?
 Age –related differential diagnosis for wheezing
Relative Frequency of Occurence
Condition Infancy Childhood
Asthma + +++
Airway malacia ++ +
Cystic fibrosis +++ +
Foreign body ++ +++
Airway infection +++ ++
Bronchopulmonary dysplasia +++ +
Primary ciliary dyskinesia + ++
Bronchiectasis + +
Congenital anomalies +++ +
(vascular ring)
Vocal cord dysfunction - ±
Tumors ± ±
Aspiration syndromes (including + ±
gastroesophageal reflux
Pulmonary edema + +
-, unlikely to present in this age grup; +, likely to present in this age grup
Key points for History Taking
 Investigations
• Chest x-ray
• Cough swab
• Nasopharyngeal aspirate / throat swab
• Skin prick test / spesific IgE to inhaled allergens
 Referral Criteria
When further evaluation is needed ?
 Managements
• Primary prevention is not possible
• Allergen avoidance is of limited value
Controversial :
Bronchodilators can improve parent rated symptom
scores & measures of lung function
Oral corticosteroids
Inhaled corticosteroids
Montelukast
Nebulised hypertonic saline
• EDUCATION
 Key Points
• Wheezing in children of pre school age is very
common
• Wheeze in young children is now categorized as
either episodic (viral wheeze) or multi trigger wheeze
• Multi trigger wheeze may be precipitated by tobacco
smoke exposure, allergens, exercise, viral infection
• Diagnosis of wheeze can be complicated by other
conditions
 Key Points
• Clinical assesment should be detailed & take account of
multiple symptoms
• Other than history taking & examinations, further
investigations may be needed
• GP’s should aware of ”red flags” which should prompt
immediate referral
• Limit allergen exposure & should be adapted to
individual patient
 Key Points
• A trial of reliever treatment should only be continued if
there is objective benefit

• Controller treatment may be indicated in some cases

Parent Education Is Essential
 Modified Asthma Predictive Index (API) vs Original
1) A history of ≥ 4 wheezing episodesAPI
with ≥ 1 physician’s diagnosis
2) In addition, the child must meet ≥ 1 of the following major criteria or ≥ 2 of the
the following minor criteria :
Major Criteria
Modified API Original API
Parental history of asthma Parental history of asthma
Physician diagnosed allergic dermatitis Doctor-diagnosed atopic dermatitis
Allergic sensitization to ≥ 1
aeroallergen
Minor Criteria
Modified API Original API
Allergic sensitization to milk, egg, or Doctor-diagnosed allergic rhinitis
peanut
Wheezing unrelated to colds Blood eosinophils ≥4%
Blood eosinophils ≥ 4%

Cave AJ, Atkinson LL. Asthma in Preschool Children : A Review of the Diagnostic Challenges. J Am Board Fam Med. 2014; 27 :
538-548
 NHBLI’s CARE Network clinical trials investigating the management of
preschool children with recurrent wheezing

Preschool children with a history of episodic wheezing, who are at high risk for
asthma (based on API), but without evidence of day-to-day impairment, improved
clinically from exacerbations requiring OCS. ICS could be given early during
respiratory tract illness

ICS response among preschool children with episodic wheezing is heterogeneous.

Children with atopic manifestations & with greater disease burden may experience
greater ICS response

The role of OCS in the treatment of acute episodic wheeze in preschoolchildren is yet
to be determined

Beigelman A, Bacharier LB. J Allergy Clin Immunol Pract

Additional clinical trials is needed ?
 Take Home Massages
Viral infection  wheezing
Evironmental control : Environment tobacco smoke (ETS)

Early childhood wheezing : Episodic viral wheeze, Multiple trigger wheeze

Sign of atopy Physical examination

Communication
 Enviromental Tobacco Smoke (ETS)

Maternal prenatal smooking :  lower levels of lung function of

infants  viral-induced wheeze

ETS
Health hazard,
Cost /⬆︎ medical
expenditure

Lam,et al. Pediatrics 2001; 107;e91

 Tips for Doctors

Be sure what exactly family means

by wheeze

If inhaled drugs in particular do not seem

working, check that they’re being properly
administered (inhaler MDI/ baby)
 Patient - Doctor Partnership

1. Take a careful history

o Friendly manner
o Allow the patient to express their goals, beliefs and concerns
o Empathy and reassurance
o Encouragement and praise
2. Perform a thorough clinical examination
3. Perform other tests
4. Provide appropriate (personalized) information
5. Management
6. Feedback and review