In toddlers with wheezing, how should I evaluate and treat the patient?

Does he/she have asthma?

This is one of the most common reasons for us to see children ages 1-3 in our clinic.  These children present with wheezing or persistent cough.  There are generally two categories of toddlers with wheeze or persistent cough, those who are otherwise well and those who are not. 

In the toddler who has a persistent cough or wheeze or who has recurrent symptoms over several months and who is not growing well, there is a long differential to consider and usually the history will give you some clues.  The history of choking or sputtering with feeds, or frequent vomiting might lead you to aspiration.  Recurrent sinus disease, oil in the stools or abdominal pain, and cough or pneumonia might point you towards cystic fibrosis. Recurrent ear infections, sinus infections, and wheeze or cough with recurrent pneumonias might make you think of immunodeficiency such as IgA deficiency.  Recurrent cough or wheeze with an oxygen requirement might suggest congenital heart disease or interstitial lung disease.  All of these diseases can cause heterogeneous inflammation and wheeze like asthma.  In many, you can also hear crackles on exam due to increased secretions even when the child is well.  In some, you might even see clubbing if the child has severe lung disease or hypoxia.

The more common scenario is a child who is otherwise healthy and thriving but has recurrent or persistent cough or wheeze.  In this case, the differential really includes asthma, anatomic abnormalities and airway compression (although if the anomaly or compression is severe, the child may also have some growth delay), and the physical exam can help.  For example, if the child has a monophonic sound or a focal wheeze on exam, then anatomic abnormalities such as tracheomalacia are more likely.  If the physical exam is normal with no crackles or clubbing or monophonic wheezes and the child responds to albuterol, then asthma should be on the top of the differential. 

How do you diagnose asthma?

According to the draft National Asthma Education and Prevention Program 2007 guidelines, asthma can be diagnosed in any patient who has recurrent symptoms of obstruction and responds to albuterol when you are sure they do not have anything else.  Using this definition, asthma can be diagnosed at any age.  The key, of course, is to work through the differential carefully, especially in the youngest children.

Who is most likely to have asthma?

You should suspect asthma, and therefore try albuterol, in children who have frequent or prolonged bouts of cough and have a family history of asthma, children who have eczema, or children who have specific allergic triggers such as seasonal allergies, animals or foods.  Children who are not allergic will often describe specific triggers for the cough or wheeze such as respiratory infections, exercise, or cold air. They may also say that the cough comes every night.  In these children, you can try albuterol to see if it mitigates their response to the exposure.  Finally, any child with a recurrent cough or wheeze can try albuterol just to see.  If they have a response, and they do not meet the criteria for any other diagnosis, asthma is most likely.

Which toddlers will grow out of their asthma?

According to the asthma predictive index that was creating using data from a cohort study in Tucson, toddlers with a history of recurrent wheeze are most likely to continue wheezing past age 6 if either of their parents have asthma or they have eczema.  They may also have persistent symptoms if they have two of the following:  wheeze between illnesses, positive allergy testing, or an elevated marker of allergy such as Ige or eosinophils.  Lung function testing may also provide some information and can be done starting at age three at The Children's Hospital.

Pulmonary Breathing Center physicians with pediatric pulmonary and sleep medicine expertise are available for phone consultation, outpatient consultations and inpatient care and can be reached at (720) 777-6181.  Please feel free to contact them with additional questions regarding your specific patients.