Recurrent Wheeze

Recurrent wheeze in children is repeated episodes of wheeze (three or more in a year) and requires distinction between asthma, viral-induced wheeze and other causes.

• Common causes in young children are viral-induced wheeze and early asthma.
• Other causes include gastro-oesophageal reflux with aspiration, foreign body, cystic fibrosis, primary ciliary dyskinesia, bronchiectasis, tuberculosis, congenital airway anomalies, vascular ring, heart disease, immunodeficiency and HIV.
• Atopy and tobacco smoke raise risk of persistence.
• Poor response to usual asthma therapy should prompt search for another cause.

Pattern of recurrence points to the cause.

• Episodes only with colds (viral), or also with exercise, allergen and night-time cough (asthma).
• Persistent wheeze from birth or the first weeks suggests structural problems (tracheomalacia, vascular ring).
• Wheeze with chronic wet cough, steatorrhoea or poor growth suggests cystic fibrosis.
• Wheeze after feeding or vomiting suggests reflux and aspiration.
• Sudden onset after choking suggests foreign body, with unilateral signs.
• Fixed, monophonic wheeze or focal findings suggest airway obstruction.
• Clubbing, failure to thrive, recurrent infections, or chronic ear discharge point to bronchiectasis, primary ciliary dyskinesia or immunodeficiency.
• Differential diagnosis: asthma, viral-induced wheeze, foreign body, cystic fibrosis, primary ciliary dyskinesia, tracheobronchomalacia, reflux, bronchiectasis, tuberculosis, vascular ring, cardiac disease, immunodeficiency and HIV.
• Complications: school absence, repeated admission, poor sleep, growth impairment, chronic lung damage and loss of lung function.

Investigation is directed by history.

• Detailed history: onset, triggers, associated symptoms, atopy, feeding, family history, smoke exposure.
• Growth chart and full examination including clubbing, chest shape, heart sounds and ENT.
• Chest X-ray (hyperinflation, focal change, heart size, aspirated foreign body).
• Spirometry with bronchodilator reversibility from age 5 to 6 years, peak flow diary and fractional exhaled nitric oxide where available.
• Full blood count with eosinophils, total and specific IgE, skin prick tests.
• Sweat chloride, immunoglobulins, HIV test, tuberculosis tests, nasal nitric oxide and ciliary function tests as indicated.
• Reflux and swallow tests, bronchoscopy, high-resolution computed tomography, and echocardiography if indicated.

Treat the cause and control symptoms.

• Supportive: avoid tobacco smoke and triggers, treat rhinitis and eczema, ensure immunisation (influenza, pneumococcal), good nutrition and parental education.
• Pharmacological, relief: salbutamol 2 to 10 puffs by spacer every 4 hours as required. Short course of oral prednisolone 1 to 2 mg/kg daily for 3 to 5 days for severe attacks.
• Prevention for asthma or multiple-trigger wheeze: inhaled corticosteroid (beclometasone 100 micrograms twice daily, or budesonide 200 micrograms twice daily, increasing to the lowest effective dose), with montelukast 4 to 5 mg nightly as add-on or alternative. From age 5, step up to an inhaled corticosteroid with long-acting beta agonist combination if control is poor.
• Reflux: omeprazole 1 mg/kg once daily for 8 weeks and thickened feeds. Cystic fibrosis, tuberculosis, HIV and immunodeficiency need specific treatment.
• Procedures: bronchoscopy for foreign body, airway malacia or persistent unexplained wheeze. Surgery for vascular ring.
• Special groups: infants with wheeze from birth need specialist referral. Children not responding to inhaled corticosteroid need reassessment of diagnosis and adherence.
• Red flags: wheeze from birth, persistent wet cough, failure to thrive, clubbing, stridor, unilateral signs, recurrent pneumonia, hypoxia, and poor response to therapy.
• Follow-up: review at 4 to 8 weeks and then every 3 to 6 months; step down after 3 months of control. Refer to a paediatric respiratory specialist if the diagnosis is uncertain or control is poor.