Caring for wheezy infants and toddlers

THE relatively small size of infants’ airways means that narrowing of small and medium sized ones due to mucus and/or bronchoconstriction leads to rapid respiratory compromise. Two of the most common disorders in this age group are discussed below.



Bronchiolitis

This is exclusively a winter infection due to virus and has a peak incidence at three to four months of age.

It starts with a cold and moist cough which progresses to a wheezy/rattly chest and poor feeding. There may be a low grade fever and physical signs are of rapid breathing/recession and scattered wheezes sometimes with basal crackles.



Most infants stay at home without needing antibiotics but ex pre-term babies below 34 weeks gestation (who may present with apnoea), those where feeding stops completely and others with marked physical chest signs need assessment for possible hospitalisation. The duration of illness is usually three to six days and treatment is conservative.

Viral induced wheeze (VIW)

Again a cold with any common cold virus precedes the chest symptoms and peak incidence is six months to three years.

Although having cough and a rattly chest the infant may be well (a happy wheezer). Predisposing factors include parental smoking, communal childcare, several older siblings, previous similar episodes, and chronic lung disease.

Most young children with asthma do well and are managed in a primary care setting. Only a few selected cases need outpatient paediatric referral.

There is no association with atopy including eczema or perennial rhinitis and episodes may be mistaken for a chest infection.

Evidence of cough, wheeze and minimal fever with no focal chest signs support the diagnosis of VIW. In pneumonia the infant is toxic/ill, febrile with focal chest signs.

Recurrent episodes with or without antibiotic use point towards VIW. Clinical assessment is to categorise into severity and most are mild. Those in the intermediate or high-risk groups may need to be seen urgently in a paediatric assessment unit.

Treatment is initially with high dose inhaled salbutamol with a spacer and facemask in those over eight months of age. Below this age bronchodilators rarely work.

Often six to eight puffs will be needed and doses can be repeated after three to four hours and parents will need tuition in inhaler technique.