Clinical Review

Managing wheeze in preschool children

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g15 (Published 04 February 2014) Cite this as: BMJ 2014;348:g15
  1. Andrew Bush, professor of paediatrics and head of section (paediatrics)1, professor of paediatric respirology2, consultant paediatric chest physician3,
  2. Jonathan Grigg, professor of paediatric respiratory and environmental medicine4,
  3. Sejal Saglani, reader in paediatric respiratory medicine35
  1. 1Imperial College, London UK
  2. 2National Heart and Lung Institute, Imperial College, London, UK
  3. 3Respiratory Paediatrics, Royal Brompton Harefield NHS Foundation Trust, London, UK
  4. 4Blizzard Institute, Barts and the London Hospital, London, UK
  5. 5Leukocyte Biology, NHLI, Imperial College London, UK
  1. Correspondence to: A Bush, Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London SW3 6NP, UK a.bush{at}imperial.ac.uk

Summary points

  • Preschool wheeze should be divided into “episodic viral” and “multiple trigger” according to the history, and these categories, which can change over time, should be used to guide treatment

  • No treatment has been shown to prevent progression of preschool wheeze to school age asthma, so treatment is driven solely by current symptoms

  • In all but the most severe cases, episodic symptoms should be treated with episodic treatment

  • If trials of prophylactic treatment are contemplated, they should be discontinued at the end of a strictly defined time period because many respiratory symptoms remit spontaneously in preschool children

  • Prednisolone is not indicated in preschool children with attacks of wheeze who are well enough to remain at home and in many such children, especially those with episodic viral wheeze, who are admitted to hospital

Lower respiratory tract illnesses with wheeze are common, occurring in around a third of all preschool children (here defined as aged between 1 and 5 years). They are a major source of morbidity and healthcare costs, including time off work for carers, and are often difficult to treat. This review focuses on the two areas in which there have been recent developments. The first is the classification of these children by symptom pattern into “episodic viral” and “multiple trigger” wheezers.1 These phenotypes can change within an individual over time,2 but they are a useful guide to current treatment, and there are also physiological and pathological rationales for their use.3 4 The second area is the recent series of large randomised controlled trials of treatment, specifically related to the roles of intermittent montelukast and inhaled and oral corticosteroids. These trials have shown clearly that inhaled corticosteroids and prednisolone in particular have been misused and overused in the past, mandating a reappraisal of treatment algorithms.

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