Pre-school Wheeze: The Bane of a Paediatrician

S1C – Pre-School Wheeze/Asthma in Children
PRE-SCHOOL WHEEZE: THE BANE OF A PAEDIATRICIAN

Andrew Bush
Imperial College and Royal Brompton Hospital, London, United Kingdom

Preschool wheeze is common, and after a diagnostic evaluation, management traditionally relies on parental perception of the pattern and severity of symptoms. There is no treatment which prevents progression of preschool wheeze to school age asthma, so treatment is based on current problems not future prevention. Many pre-schoolers have no evidence of Type 2 inflammation and do not respond to inhaled corticosteroids (ICS). Increasingly, aeroallergen sensitization and peripheral blood eosinophil count, the latter of which can be a point of care test, have been used both to predict response to ICS and in the case of blood eosinophils, a marker of risk of a wheeze attack. There is also mounting evidence that chronic bacterial and viral infection may be more important than previously thought. In many cases, clinicians are left having to perform a therapeutic trial of ICS. It is recommended that a three-step protocol is used. Step 1, Beclomethasone 200 mcg bd for 6-8 weeks. If there is no response, stop treatment because this is not steroid-sensitive disease. If there appears to be a response, again stop treatment and monitor (Step 2). If symptoms recur, then beclomethasone is titrated to the lowest dose to control symptoms. Other treatments to be considered include montelukast (but significant neurocognitive side-effects) and tiotropium (more data needed). Treatment needs to move from blind trials based on symptoms to pathology-directed therapy