Recurrent Wheezing in Early

Childhood: Is it Asthma ?

Nastiti Kaswandani
 Topics
Why young children are susceptible of
wheezing
Differential diagnosis of recurrent wheezing
When recurrent wheezing in early childhood is
asthma
 INTRODUCTION
Approximately 1 in 3 children has at least 1 episode of
wheezing prior to their 3rd birthday, and the cumulative
prevalence of wheeze is almost 50% at the age of 6 yrs
Most wheeze is associated with viral upper respiratory tract
infections, which can recur frequently in this age group.
Viral respiratory tract infections include rhinoviruses, influenza
viruses, parainfluenza viruses, respiratory syncytial virus (RSV),
enteroviruses, and certain strains of adenovirus
Parents concern the possibility of asthma in early childhood
 Sites & Sounds of Airway Obstruction

Snoring

Voice quality Inspiratory

Stridor
Cough quality

Expiratory
Stridor
 Obstructive airway noises
characteristics cause

Stertor/ Low pitched & nasal or pharyngeal

snoring inspiratory noise obstruction

Stridor Musical, often harsh turbulent air through a

and high-pitched narrowed segment of the
sound large airways

Wheezing High-pitched sound, turbulent airflow through

best heard over the obstructed small airways
chest
Children = mini Adults

and its also seen in wheezing

Tubular Fluid Dynamics

Pouseuilles law

resistance is related to
the inverse of the radius
to the fourth power
So that decrease 1 mm diameter of
childrens airway will cause a big
problem
Not All Wheeze is Typical
Differential Diagnosis of Wheezing
History-taking / Anamnesis

Weiss LN. Am Fam Physician 2008;77:1109-14.

Does recurrent typical wheezing
always indicate asthma ?
VIRAL INFECTION and ASTHMA
Rhinovirus - Asthma

Gern JE. J Virol 2010;84:7418-26

Jackson DJ, Gangnon RE, Evans MD, Roberg KA, Anderson EL, Pappas TE. 2008

By age 3 year wheezing with virus was strongly associated with asthma at
age 6

16
Brand. ERJ. 2008;32:1096-110
Taussig LM, Wright AL, Holberg CJ, Halonen M, Morgan WJ, Martinez FD.2003

Children who wheezed at different time didnt have the same

patophysiology

Young children with wheeze have 3 different phenotype

Transient infant wheezers
Non atopic wheezers
Atopic wheezers

18
 Transient Early Non-Atopic Asthma
Low LFT at
Wheezers Wheezers
birth
Wheezing prevalence

BHR of
atopic
asthma

Post
RSV

0 3 6 11
Age (years)
Hypothetical peak prevalence by age for the 3 different wheezing phenotypes.
The prevalence for each age interval should be the area under the curve. This does not
imply that the groups are exclusive.
 Transient infant wheezers
Wheeze during the first 2-3 yr of life, no wheeze after 3 yr
No family history of asthma, atopic dermatitis, eosinophil, IgE
Low level of lung function
Non atopic wheezers
Continue to wheeze > 3rd yr after having LRI in early life
Alteration of airway control tone after viral infection
Atopic wheezers
Likely to be sensitized at 6 against common aeroallergens
Symptoms started before 3 yr
Lowest level of lung function at the age of 6 and 11 yr
Highest levels of IgE at the age of 6 and 11

20
ASTHMA PREDICTIVE INDEX

To be positive for this index, children needed to have reports of

recurrent episodes of wheezing, and
1 of 2 major criteria :
atopic dermatitis
parental asthma
or 2 minor criteria :
blood eosinophilia
wheezing apart from colds
allergic rhinitis

75% with postive index: active asthma in 6-13 years

68% with negative index: never had symptoms of asthma
21
 Early life recurrent wheezer

What should we do ?
What should we give ?
What should we inform to the parents ?
 Environment Manipulation
Reducing tobacco smoke exposure
Allergen avoidance
Patients and parents educations
Pharmacological therapy

Brand PLP, et al. Eur Respir J 2008;32:1096-110.

 GINA (Global initiative for asthma)
Highly suggestive of diagnosis asthma in younger children:
Frequent episodes of wheeze (>1 / month)
Activity induce cough or wheeze
Nocturnal cough in periods without viral infection
Absence of seasonal variation in wheeze
Symptoms that persist after age 3

Confirming diagnosis:
A trial of treatment with short-acting bronchodilator and inhaled
glucocorticosteroid

25
 TREATMENT

Inhaled Corticosteroid for wheezing < 5 yr :

Recurrent wheezing or asthma in young children improve their symptoms
and lung function during treatment with ICS
ICS outcomes are better when asthma is diagnosed early, allowing the
initiation of treatment within the first 2 yr of illness
ICS should be introduced when the symptoms occur > 1 or 2 times a week, or
when > 2 attack a month
Early intervention with anti inflammatory drugs could change the natural
course of the disease

Rodriguez. Pediatrics 2009;123:e519-25

26
Pedoman Nasional Asma Anak
INDONESIA
under 5 asthma diagnosis
 Therapetic Approach
SABA for wheezing episodes
Persistent symptoms : ICS for 3 months
If persist : adding ALTR
If still failed : Evaluate
Diagnosis of other than asthma
Compliance of device and drug usage
Risk factors
 Summary
Wheezing is the one of the most frequent sign/symptoms
in early childhood
A careful clinical approach should be done when facing
wheezing in children
Recurrent wheezing does not always indicate asthma
Inhaled corticosteroid showed good response in patients
with positive asthma predictive index
Positive asthma predictive index: 1 of 2 major criterias
(eczema & parental asthma) OR 2 of minors (eosinophylia,
wheezing without cold and rhinitis)
 Proposed Post-viral Increased AHR mechanism

increased vagally mediated

bronchoconstriction
sensory C fibre stimulation
epithelial damage
increased neural sensitivity
increased allergen penetration
reduced neutral endopeptidase and
increased tachykinins
reduced protective mediators, eg.
EpDRF,PG E2
increased in late phase reactions
virus spesific lgE production
Allergen sensitisation
Mediator release
cytokine production, eg. IL-11
receptor down regulation
Factors affecting the variable and persistent components
of AHR

Busse WW. Chest 2010;138:4S-10S

 lung function deficits in
school-age children with
wheezing

?
secondary to
Airway
airway
remodelling
inflammation
Henderson J. Thorax. 2008;63:974-80.
Signs & Symptoms Working Diagnosis Further Evaluation