I never quite understood why wheezing in pre-school children is not meant to be called asthma when it looks like asthma, sounds like asthma and behaves like asthma, but apparently the reason is the absence of eosinophilic airways inflammation. Some of these wheezers will go on to develop actual asthma, and some will grow out of the wheezing. Treatment makes no difference to risk of progression to asthma and should thus be aimed at current symptoms.
Look for red flag signs/symptoms, and also make sure, if possible, that this is actually wheeze and not a misinterpretation of something else. Having done that, the most useful subdivision is:
- Episodic viral wheeze (hereinafter called EVW for speed)
- Multiple trigger wheeze (MTW)
Regular treatment is not helpful for EVW (the possible exception being severe cases, since there are fewer data on these and also there’s always the possibility that it may in fact be MTW with intercurrent symptoms subtle enough in comparison with the exacerbations to have escaped the parents’ notice). Treat only during episodes, with treatment given until symptoms resolve.
- First line: SABA or SAAC
- Second line: surprisingly, should probably be a leukotriene inhibitor rather than inhaled steroids, as the former has at least some evidence in favour of its use whereas the latter only appear to work at insanely high doses.
For MTW, use regular treatment – in this case, either an ICS or an LT3 inhibitor as there doesn’t seem to be any evidence as to which, if either, is better. However, treatment should initially be given as a 4 – 8/52 trial & then paused and the effects of both treatment and cessation assessed, to avoid a situation where coincidental spontaneous resolution of symptoms makes it look as though administration of the drug has had an effect. (The same applies to the rare cases where regular treatment is being considered for episodic viral wheeze.) If symptoms recur when off the preventer, restart it and titrate it down to the lowest dose that controls symptoms.
Presumably it’s also appropriate to have trials off the preventer every so often after its use has been established, to check whether the child has grown out of the symptoms; however, the article didn’t discuss this. Maybe a pragmatic approach would be to try the child off preventers as they approach school age.
Finally, a couple of things that are not helpful in most cases:
Oral prednisolone: no help in two trials of children with relatively mild exacerbations. The conclusion is that if a child’s condition is mild enough for admission to be unnecessary, then it’s mild enough that prednisolone is not going to help. (Even in children requiring admission, it may not be needed; there doesn’t seem to be any data about the usefulness of prednisolone in children with severe exacerbations of preschool wheeze.)
Nebulisers: no better for administration than MDIs. They may be useful in acute exacerbations, but there’s no point in using them for regular community administration.