Download Wheezing Toddler

Recurrent wheeze with viral illnesses in a 3 year-old Hispanic girl, who is otherwise healthy
Author: John Mark, MD, Last updated: April 2009
Lupita Ramirez is a 3 y/o Hispanic girl who comes to the clinic today as a new patient and the
chief complaint of frequent upper respiratory tract infections (URI’s) and persistent cough. The
URI’s seem to occur almost every month and the cough persists for over 2 weeks before finally
going away.
History of Present Illness:
These frequent URI’s started shortly after she began attending daycare. This has now been over a
year and the illnesses continue even through the summer months. The illness will often start with
some nasal congestion and then night time cough. The cough increases to where she has difficulty
sleeping and with normal activity. At times her breathing is labored and she has made whistling
or wheezing noises.
The parents have taken her to the local urgent care clinic in addition to their primary care
physician’s office. She has been give multiple medications including decongestants, antibiotics
and even a “breathing treatment” which seemed to help. She has also taken several courses of oral
steroids this last year. When she does not have a cold, she can run, sleep, play and not have any
respiratory symptoms.
PMH:
She has never been hospitalized or had a significant illness. Although she once was thought to
have pneumonia, she did not require oxygen therapy or require hospitalization. She has not had a
chest radiograph but has had several blood tests, all normal.
She was a full term baby, no problems in the first year of life, no skin conditions and no problems
with recurrent or persistent ear infections. She has a normal diet and will eat all types of food. She
still likes to have a bottle of milk when she goes to bed.
Medications:
Currently she is taking no medications, although she has a “machine” at home and the parents
will give her albuterol when she is having trouble with her breathing.
Immunizations:
Up to date
Allergies:
No known allergies to medications
Social History:
Lives with mother, father, two older brothers and maternal grandparents. Both her parents and
grandparents are field workers. Her father smokes but only “outside” as does the grandfather.
They have one dog but it is outdoors year round.
Family History:
Negative family history for any respiratory problems. The mother has mild hypertension and one
of her older brothers has a seizure disorder.
Review of Symptoms:
When she does not have a URI, she has a negative review of symptoms. As stated earlier, with an
URI, she will cough, occasionally wheeze and have difficulty sleeping and playing. She has had
post-tussive vomiting when she is sick.
Otherwise the ROS was noncontributory. She is growing well (constitutional), no recent ear or
throat problems (ENT), heart murmurs (CV), abdominal pain or diarrhea/loose stools, dysuria
(GU), blood problems (Heme), muscle aches (muscuoskeletal) or problem relating to endocrine,
neurological systems. The family appears to be close- all 6 relatives came to this health care visit.
Physical Examination:
Alert and very active 3 y/o.
Afebrile, RR-22, HR-92, BP-97/56, Oxygen saturation- 99% room air
Weight -17 kg (95% tile) and Height -95 cm (75% tile).
Relevant findings were significant for the lack of any positive findings. Her HEENT exam was
normal with no tonsilar enlargement. Her chest was clear to auscultation with no increase work of
breathing. CV exam was normal, no murmurs were appreciated and her abdominal exam was
without organomegaly, normal bowel sounds and soft. Her extremities and skin were normal for
strength and lack of any rash or birthmarks. She was developmentally normal for her age.
Based on Lupita’s history and physical exam what diagnosis are you considering?
Lupita appears to be a very healthy little girl, negative family history for chronic
respiratory illnesses but yet, she is often sick- even has respiratory distress.
Could this be some type of immune problem since she is sick so often?
Could this be some type of asthma although she doesn’t have a family history and she
has no evidence of allergies?
View the list of possible diagnosis:
• Asthma
• “Reactive airway disease”
• Airway abnormality causing respiratory distress with URI’s
• Immunodeficiency with recurrent infections
• Allergies or some type of response to environmental irritants
• Cystic fibrosis
• Primary ciliary dyskinesia (immotile cilia syndrome)
• Gastroesophageal reflux
• Over anxious parents in a little girl who has frequent colds since she attends daycare
(patient appears normal with normal exam)
Learning issues (considerations):
1. How is the differential diagnosis best approached?
1. Wait until she gets another URI and then try to see her in the office so you can
evaluate her lung exam and response to treatment?
2. Obtain a chest radiograph?
3. Obtain lab tests including immunoglobulins, blood count, and arrange a sweat
test?
4. Refer her to a Gastroenterologist for evaluation for reflux?
5. Giver her prescriptions for asthma medication such as inhaled steroids and
bronchodilators (especially since she already has a compressor/nebulizer at
home) and tell the family to start them when she becomes sick?
Many children will have persistent cough and even wheezing with viral infections in the first few
years of life. In some studies, 20-30% of children with a viral lower respiratory tract infection
will wheeze. However, the vast majority (over 60%) will have normal lung function and the
wheezing associated with viral infections will disappear by 6-7 yrs of life.
What one needs to determine is if Lupita is one of these children or does she has some underlying
respiratory problem such as asthma, abnormal airways, immune dysfunction or environmental
irritants that are causing her to be sick often and have this persistent cough.
Since the majority of children with viral induced cough and wheeze improve with age, what are
indicators that Lupita will be one of these children? The family and past medical history are
important in determining the chance of Lupita’s problem being asthma or some chronic related
condition. If there is a family history in the parents of asthma, if Lupita has had atopic dermatitis
or if she has had esosinophils on a blood count, then the chances of her “outgrowing” this viral
induced wheezing are much less. Theses findings along with a history of cough or wheeze apart
from URI’s or with vigorous activity would lead one to believe this could be asthma.
2. Since Lupita does not have this family history or problems when she doesn’t have a URIdoes that mean this is not asthma? Yes or No?
No, since there are other factors including certain viral infections that may lead to chronic asthma
and the possibility of 2nd hand smoke exposure which can cause chronic asthma in children.
3. What is the likelihood of other diagnoses to be present in Lupita?
Taking them one by one:
1. “Reactive Airway Disease”- probably no such entity, so can eliminate from the
differential.
2. Cystic fibrosis- can be difficult to diagnose especially in Hispanic children since
they may not have pancreatic insufficiency, the lack of pneumonia and growth
over the 75%tile would make this unlikely
3. Primary ciliary dyskinesia would have persistent cough even with no URI (80%
of the time) and usually have recurrent ear infections
4. With no history of vomiting or abdominal pain or chronic cough apart from
URI’s- gastroesophageal reflux would be unlikely.
5. Immunodeficiency would usually present earlier, more significant illnesses such
as pneumonia, recurrent ear infections and usually accompanied by high fever.
4. Often response to treatments can lead one to the correct diagnosis. Lupita did seem to get
better when she was given the medication with the home nebulizer. If she was older (>5 yr),
one could consider what test to help you make the determination if she had reversible airways
(asthma)?
Spirometry before and after bronchodilator. If there was evidence of airway obstruction
on her lung function tests that improved after a bronchodilator was given, then one would know
that she does have asthma (airway reversibility is the definition of asthma).
http://www.nhlbi.nih.gov/guidelines/asthma/
5. What would be the best evaluation for Lupita?
Answer: Chest radiograph, preferably two views
During that first clinic visit, a chest radiograph should be obtained. The value of knowing how
her lung appear on x-ray is important. Does she show evidence of chronic changes
(hyperinflation, bronchial cuffing, mucus plugging)? Does she have normal appearing airways?
Does her heart and other organs appear to be in the correct position (situs inversus is more
common in primary ciliary dyskinesia). Although chest radiographs are not recommended for
children with frequent URI’s, Lupita has had significant respiratory distress with her illnesses, so
a baseline film could be helpful.
6. Would you start any medications for Lupita?
Answer: Yes
It is not uncommon for parents to be reluctant to give medications to their children especially
when they appear to be so healthy in between these various illnesses. However response to
treatment in infants and toddlers can be extremely helpful. Even using the bronchodilator (usually
albuterol) at the very early signs of the URI instead of waiting till Lupita is having difficulty
breathing may be what she needs to keep her from becoming so sick.
If she does respond to the bronchodilator (an asthma medication), the one will need to evaluate
her control to determine if other asthma medications (so call controller medications such as
inhaled steroids or monetelukast) should be considered.
7. Is there other ways to help Lupita besides giving her medications?
Since Lupita is frequently ill with viral infections, improving her immune system through diet
and healthy habits may have a significant impact. Below are some things to consider when
discussing her care with her family:
• Eliminate exposure to 2nd hand cigarette smoke including the house, the clothes that
father and grandfather wear when they smoke and especially in the car or other enclosed
spaces (garage, shed, etc).
• Decrease or eliminate cow’s milk and dairy products, especially since Lupita is becoming
obese. Often dairy products may exacerbate mucus production and they also add extra
calories that she could be receiving from healthier sources although calcium intake is
important. This would also include stopping the bottle of milk prior to bedtime.
• Increase her fresh fruits and vegetable intake since it has been shown that these foods are
rich in antioxidants and children who have diets rich in these foods have better lung
function.
•
•
•
Increase her diet with omega 3 fatty acids using green leafy vegetables, flaxseed and fish
(sardines, salmon, herring as examples).
Ensure she is getting 8-10 hours of sleep since sleep and rest can reduce the duration and
severity of URI’s.
Good multi-vitamin including one that has Vitamin C (250 mg), Vitamin A (5,000 IU),
Vitamin E (30 IU), Zinc (7.5 mg), Vitamin D (400 IU), Vitamins B6 and B12 along with
Magnesium (dosing depends on preparation)
In summary, children often develop frequent URI’s (6-8/year is common) and a significant
proportion will develop cough and wheeze. Most children’s symptoms disappear by age 6 years,
however, some will have persistent symptoms especially if there is a positive family history for
asthma and allergies. Determining if the child responds to asthma medications, ensuring they use
the medication correctly and in a timely manner in addition to improving nutrition and lifestyle
habits can help decrease illnesses both in duration and severity.
Summary of evaluation and therapies:
• History is key in making the correct diagnosis in addition to response to treatment
• Initial chest radiograph is important in a child with recurrent respiratory symptoms
that cause distress
• Thorough review of airway irritants such as 2nd hand smoke exposure is important
to decrease chronic respiratory symptoms in children
• Encouraging nutritional changes with such things as fruits, vegetable, foods rich in
omega 3 fatty acids all may lead to improved lung function in the growing child
• Vitamins and supplements may also help the child’s ability to fight off viral
infections and have a quicker recovery.
• If a child does not respond to treatment discussed, then further testing for such
things as cystic fibrosis, ciliary dyskinesia, immune deficiency and gastroesophageal
reflux should be considered.
REFERENCES
Martinez FD, et al. Asthma and wheezing in the first six years of life. N Engl J Med 1995;
332: 133–38.
Sly, P et al. Early identification of atopy in the prediction of persistent asthma in children
Lancet 2008; 372: 1100–06
Fahy, J. O’Bryne P. “Reactive Airways Disease” A Lazy Term of Uncertain Meaning that
should be Abandoned. Am. J. Respir. Crit. Care Med., Volume 163, Number 4, March
2001, 822-823
http://www.cff.org/
Brown, DE et al. Early lung disease in young children with primary ciliary dyskinesia. Ped
Pulm 2008; 43(5): 514-6
Chatzi L, Bibakis I, et al. Protective effect of fruits, vegetables and the Mediterranean diet
on asthma and allergies among children in Crete. Thorax 2007;62:677–83.