nPersonal opinio lManagement of wheeze and cough in infants and pre-schoo echildren in primary car

Pauln Stephenso

nIntroductio is, well established in adults 2thoughs there remain somer controversy about its diagnosis in children eve Managementa of wheeze and cough in children is sinceh Spelman's uncontrolled study of children wit commonm problem in primary care. In this paper I ai nchronic cough successfully treated according to a tod provide a few useful management tools with regar .asthma protocol 3gWithout the ability to perform lun toe diagnosis, the role of a trial of treatment, and th functione tests in pre-school children, care must b rationalee for referral. For an in-depth review see th takent to exclude other diagnoses. A persisten article. in this journal two years ago by Bush 1 eproductiv coughc may be due solely to chroni catarrhe with postnasal drip, but early referral may b sPresentation of Symptom needed. A persistent dry cough,n worse at night and o exercise,s and without evidence of other diagnose Ity is always worth asking parents what they mean b warrants. a trial of asthma treatment thed term 'wheeze' or 'cough'. The high-pitche musicaln noise of a wheeze usually on expiratio Thef younger the child, the longer the list o shouldy not be confused with the sound of inspirator differentialo diagnoses and the more one has t sstridor. The sound of airflow through secretions i econsider possibilities other than 'asthma'. Thes ddifferent again, and parents may describe their chil linclude upper airways disease, congenital structura 'vomiting'g when, in fact, the child has been coughin diseasel of the bronchi, bronchial or trachea severely and bringing up phlegm or mucus. rcompression by cardiac enlargement o -lymphadenopathy, foreign body or tumour, gastro oAn acute presentation requires immediate referral t foesophageal reflux, laryngeal problems, causes o hospitale if appropriate. Probably the commonest caus persistentd productive cough such as cystic fibrosis an inl the infant is bronchiolitis, and in the pre-schoo primary- ciliary dyskinesia as well as immuno child,s viral induced wheeze or croup. Unilateral sign sdeficiency and miscellaneous causes such a ecould represent an inhaled foreign body, and a febril .bronchopulmonary dysplasia and pulmonary oedema 1 child. with tachypnoea may well have a pneumonia nPaul Stephenso Pertussisf may have to be considered, particularly i rGP, PCRJ News Edito fthere is a relevant non-immunisation history. I sLongitudinal Studies and Wheezing Phenotype immediater transfer to hospital is not required, fo :Correspondence to exampleo after nebulisation, it is of course essential t Oure understanding of the natural history of wheez nDr. Paul Stephenso reviewr the situation closely and give parents clea (andt cough) has increased considerably over the las 4 sChristmas Malting .instructions regarding review teny years. The British National Cohort Stud ySurger reportedr on 880 children given a label of asthma o lWith a prolonged history, the pattern of symptoms wil wheezys bronchitis before the age of 7; two third kHaverhill Suffol oftene give the clue to the underlying diagnosis (Figur grewl out of symptoms by their late teens and a smal 1).l Episodic symptoms occurring solely with a vira numbern of these had a recurrence of their symptoms i Tel: + 44 (0)1440 702203 rinfection should be differentiated from intercurrent o mida adult life. The data from Tucson, Arizon 5,6sha chronicr symptoms which may occur at night and afte provideds us with more detailed data in the early year [email protected] exercise,y perhaps in the context of a personal or famil ofr life. 862 children have been followed up for ove history of atopy. fourteens years. Using objective measurements such a JPrim Care Resp ,IgE level, methacholine response, skin prick testing 22002;11( )4:42-4 Thea concept of 'cough variant asthma' (asthm and, prospective assessment of the presence of wheeze presenting) solely as cough in the absence of wheeze Martinez et al confirmed that there are several

)Figure 1. Patterns of wheeze in young children (reproduced with kind permission of Professor M Silverman 9

eAcute episod sIntercurrent symptom cChroni

Normal lNorma Normal

eTim eTim eTim

42 Primary Care Respiratory Journal Personaln Opinio

;different wheezing phenotypes yFigure 2. Management strateg lTransient early wheezers, 60% of whom are not sRecurrent/persistent symptom wheezing by the age of 6, show a strong association with maternal smoking during pregnancy. They have reduced lung function at leasts up to the age of 6, and their prevalence peak tTrial of treatmen at. around the age of 18 months to 2 years lNon-atopic wheezers have no change in their IgE status,d and their wheezing relates to viral-induce peak flow variability. Their prevalence peaks at eMeasure respons about. 4 years lPersistent wheezers have raised IgE level at age 9 dmonths and have methacholine responsiveness an eRespons Noe respons peak flow variability. This group often have a significant family history of atopy particularly on the maternal side, have significantly reduced lung function at the age of 6 (presumably due to T-cell tStop treatmen ?Increase dosage driven eosinophil-mediated chronic sReview the diagnosi inflammation), andy their prevalence graduall rRefe increases. with the age of the cohort Recurrence eNo recurrenc Thesee groups are not supposed to be exclusive nor ar theye clear-cut, but the representation of these thre differentr wheezing phenotypes in terms of thei yhypothetical yearly peak prevalence is extremel AASTHM aNot asthm useful. rfor regula waite and se sinhaled steroid Evidencer from other longitudinal studies (fo e+/- leukotrien eexampl 7)s suggests that there may be a genetic basi treceptor antagonis forf this phenotypical difference. Amongst children o ifd neede dmiddle-aged patients with previously diagnose asthmae or 'wheezy bronchitis', the children of th They dose of inhaled steroids needs to be sufficientl 'wheezyn bronchitis' adults had reduced lung functio highn in order to control the inflammatory process i themselves,e particularly in boys, at least raising th thef airways quickly. Adult studies using a trial o possibilityy of familial clusters of the 'wheez ltreatment as a diagnostic too 2haved used inhale .bronchitis' 'early wheezer' phenotype steroidl dosages of 2000 mcg/day together with ora -steroids if necessary. Therefore, one could use 200 nKnowledge of these different wheezing phenotypes i 400e mcg/day budesonide (or its equivalent) in th pre-schooln children is a useful tool in the consultatio undera 2's and 400mcg/day in the 2 to 5 year olds vi .largely because of the implications for treatment aChildren presenting with persistent symptoms, with .metered dose inhaler, spacer and mask if needed hpersonal and/or family history of atopy, wit Whether1 or not to use oral steroid (at a dose of symptomse of wheeze and/or cough which are wors mg/kg/daye or less) will naturally depend on th at' night or on exercise, (the 'persistent wheezer severitye of symptoms, and may depend upon th yphenotype), are likely to respond to anti-inflammator rdegree of parental anxiety, and the need fo dtreatment. Similarly, children with the 'viral induce 'something. to be done now' wheeze'r phenotype, usually with no family o personall history of atopy and with no interva Itl is essential to have regular review during the tria symptoms,c are unlikely to have IgE-mediated atopi oft treatment and then a review as treatment ceases a asthma,r and are therefore unlikely to need regula treatmente with inhaled steroids. Nevertheless, th abouth 4 weeks. Beaming smiles on the parents, wit situatione is rarely this clear, since viral infections ar lan asymptomatic child in tow, signify a successfu the' commonest trigger for exacerbations of 'true ,trial. Recurrence of symptoms needs further review .persistent atopic asthma -and discussion about long-term low-dose inhaled anti .inflammatory steroid treatment tThe Role of a Trial of Treatmen rWhen to Refe Ae trial of treatment is therefore the next step (Figur 2).e The rationale for a trial of treatment needs to b Iff there has been no response to a good trial o explainede clearly to the child's parents. Th streatment, with continuing parental anxiety, thi importantd point is that the treatment will be stoppe inevitablya casts doubt on a diagnosis of 'asthma' and afters three or four weeks, firstly to assess its succes ereferral is indicated. With only a partial respons andy secondly to see whether symptoms recur, thereb therer may still be residual parental anxiety and docto helping. to establish the diagnosis .concern regarding dual pathology

Primary Care Respiratory Journal 34 nPersonal Opinio

Asf children get older and become capable o sAcknowledgement dperforming reproducible peak flow measurements an Thise paper is based on a workshop entitled 'Th spirometry,n it is important to rethink the diagnosis i Wheezy- Infant' given as part of the Astra Zeneca latero years if symptoms persist or recur. Inability t )sponsored FORUM (Future of Respiratory Medicine edemonstrate variability with a beta-agonist challeng series.r I gratefully acknowledge the input from D would. cast some doubt on the diagnosis fDermot Ryan and Dr Vincent McGovern, both o twhom have facilitated the workshop at differen Thel younger the child, the wider the differentia Mtimes, as well as Dr John Haughney, the FORU diagnosis,d as discussed above, and the lower shoul nChairma bey the threshold for referral to a respirator .paediatrician sReference : 1.r Bush A. Diagnosis of asthma in children unde Finally,e if the parents or GP are concerned about th five. Asthma in Gen Pract 2000;)8(1 :4-6. child'sa progress in any way and things are 'not right', T2.McGarvey LPA, Heaney LG, Lawson J et. al second opinion is always warranted. Evaluation- and outcome of patients with chronic non cproductive cough using a comprehensive diagnosti Whyn bother to make the diagnosis and treat whe protocol. Thorax ;1998 53.:738-43 ?symptoms are mild e3. Spelman R. Two-year follow up of th managementn of chronic or recurring cough in childre Childrent with a good response to a trial of treatmen according to an asthma protocol. Brt J Gen Prac andr then recurrence of their symptoms warrant regula 1991 14 .:406-409 treatmentf with inhaled steroids. Give a dose o 4.l Strachan D, Butland B, Anderson H, Nationa ,inhaled steroids sufficient to control the symptoms dCohort Study: incidence and prognosis of asthma an andl then bring the dosage down to the minimum leve wheezinga illness from early childhood to age 33 in gpossible. The available inhaled steroids have differin .national British cohort. BMJ 1996; 312: 1195-9 edose-response curves, and in my opinion, budesonid 5. Martinez F D, Wright A L, Taussig L M et. al isl the initial treatment of choice in pre-schoo Asthma and wheeze in the first six years of life. children.a One may need to consider adding in Nd Engl J Me 1995:332.:133-8 sleukotriene receptor antagonist (montelukast i J6. Stein R T, Holberg C J, Morgan W let a .k Pea licensedy from the age of two). When parents quer dflow variability, methacholine responsiveness an theo role of long-term treatment, it is probably fair t gatopy as markers for detecting different wheezin mentions the data from older children which show phenotypes in childhood. Thorax 1997;52.:946-952 sthat early treatment with inhaled steroids improve 7. Christie G L, Helms P J, Ross S J et. al eOutcom long-term. lung function 8oWe are awaiting studies t ford children of parents with atopic asthma an see if these benefits can be extrapolated to the transient childhood wheezy bronchitis. Thorax ;1997 under. 5's 52:. 953-7 8.m Agertoft L, Pederson S. Effects of long ter nConclusio htreatment with an inhaled corticosteroid on growt and pulmonary function in asthmatic children. pRes In, this paper, the first of our 'Personal Opinion' series Med 1994; 8 .:373-81 In have attempted to clarify aspects of history taking i 9.r Silverman M, Ed. Childhood asthma and othe infantsh and pre-school children presenting with coug lwheezing disorders. 1995. Chapman and Hal andt wheeze, with particular emphasis on recen .Medical, London llongitudinal studies showing the hypothetica eprevalence of different wheezing phenotypes. Th youngerr the child, the more one should conside raritiesy that require referral to a respirator paediatrician.f A trial of treatment is a useful way o gestablishing the diagnosis and of differentiatin mbetween those children who warrant long-ter inhaledd steroids for atopic persistent asthma, an those who do not. n

3Cochrane Airways Group, International Symposium 200 n6 to 7 November 2003, The Royal College of Physicians, Londo

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