For children with asthma, see the CKS topic on Asthma.

Children less than 5 years of age presenting for the first time with cough and wheeze

• Assess the severity of their symptoms and their response to bronchodilators.
• Children with wheeze at high risk require immediate admission. Treat with bronchodilators whilst awaiting transfer.
• Children with wheeze at intermediate risk require a trial of therapy with a bronchodilator, and further assessment 15–30 minutes after completing treatment. This trial of therapy can be arranged in the community, or in secondary care if this is impractical.
• Children that respond to bronchodilators (no longer at intermediate risk) can be managed at home with a bronchodilator and spacer device to use as required.
• Children who do not respond to bronchodilators require hospital assessment.
• Children with wheeze at low risk:
• May be considered for a trial of treatment with bronchodilators if appropriate, depending on clinical judgement:
• To determine responsiveness to bronchodilators to guide management of future episodes.
• To relieve symptoms.
• To relieve parental anxiety about symptoms.
• For children who are managed at home, advise carers to:
• Control fever and maintain hydration with self-care measures.
• Check on the child regularly, including through the night, and seek medical advice if the child deteriorates or the carers are unable to cope.

Management of further episodes

• The management of further episodes of cough and wheeze in children under the age of 5 years depends upon whether symptoms occur only in association with a viral infection, or whether the child also wheezes in response to other triggers (possible asthma).
• For children with further episodes of viral-induced cough and wheeze, management with bronchodilators should be guided by the child's response to an initial trial of therapy.
• In children under 2 years of age who do not respond to bronchodilators, consider repeating a trial of therapy intermittently to determine whether they have become more responsive as they have become older.
• For children with suspected asthma, see the CKS topic on Asthma.

A trial of therapy with bronchodilators for children at intermediate risk:

• Expert opinion varies as to the lowest age that a trial of therapy is considered worth trying. Some experts put no lower age limit on a trial of therapy, with most recommending a trial of therapy for a wheezy child from 12 months of age onwards.
• Bronchodilation and reassessment 15–30 minutes after treatment may be carried out in the community if practical.
• The bronchodilator may be delivered either by a nebulizer or, preferably, by a metered-dose inhaler and spacer device. In children less than 5 years of age, the spacer device should be fitted with a face mask.

A trial of therapy with a bronchodilator for children at low risk:

• Prescribe a bronchodilator and spacer device, and demonstrate their use to both the child and the carer. Advise the carer to discontinue bronchodilator use if there is no clear symptomatic benefit.
• A child with clinical features placing them at low risk is unlikely to have any serious underlying pathology. Treatment with a bronchodilator is aimed only at relieving symptoms. When these symptom are mild it is a matter of clinical judgement and individual preference as to whether the inconvenience of treatment is justified by the possible reduction of symptoms.

Particular features of deterioration that should prompt carers to seek medical advice are:

• An increase in breathing rate, or any episodes of apnoea or signs of increased effort of breathing.
• A baby who is unable to take less than 50% of its normal feeds.
• Signs of dehydration such as dry mouth or infrequent passage of urine.
• A child who becomes less responsive or difficult to rouse.
• Persistent worsening in fever.

Basis for arranging a trial of therapy with bronchodilators, for a child less than 5 years of age:

• When a child less than 5 years of age presents for the first time with wheeze and a respiratory tract infection, it may not be possible to determine if this is the first presentation of asthma triggered by infection, or viral-induced wheeze.
• There is evidence that children with asthma, and children over 2 years of age are more likely to respond to bronchodilators [Wilson, 2003]. However, the response of a wheezy child to bronchodilators cannot reliably be predicted from their age or diagnosis, and experts recommend a trial of therapy to determine the child's responsiveness to treatment.
• Expert opinion varies as to the lowest age that a trial of therapy is considered worth trying, with most recommending a trial of therapy for a wheezy child from 12 months of age onwards.

Basis for not routinely recommending oral corticosteroids for children who are at intermediate risk:

• Limited evidence from two randomized controlled trials (RCTs) suggests that oral corticosteroids are of not beneficial in the treatment of preschool children with wheeze [Grigg, 2009].
• One RCT of preschool children (aged 1–5 years) who presented to an accident and emergency department with wheeze were randomized to receive either a 5-day course of oral prednisolone or placebo to be started by their parents at the start of their next attack. Data from 120 children who had a further attack of wheeze at home indicated there was no difference in the 7-day parental-assessed respiratory symptom score between children given prednisolone compared with those who received placebo [Oommen et al, 2003].
• A second RCT randomized preschool children presenting with wheeze to an accident and emergency department to receive either a 5-day course of oral prednisolone or placebo for that attack. Data from 700 children indicated that there was no difference between the groups in terms of the duration of hospitalization; symptom scores (using the Preschool Respiratory Assessment Measure [PRAM]) over the first 24 hours; parental-assessment of symptoms at day 7; or use of bronchodilator therapy with prednisolone treatment [Panickar et al, 2009].
• Expert consensus from the European Respiratory Task Force is that a trial of oral corticosteroids should probably be given only to preschool children with acute wheeze of such severity that they need to be admitted to hospital [Brand et al, 2008].

Basis for recommending admission for children who are at intermediate risk and who do not respond to bronchodilators:

• Children who have wheeze and a raised respiratory rate that does not settle with bronchodilators may have:
• Bronchoconstriction that is unresponsive to treatment, or
• Underlying pneumonia.
• Experts recommend arranging assessment by a paediatric specialist, when a child is classified at intermediate risk and the diagnosis is uncertain [NICE, 2007].

Basis for recommendations of when a carer should seek further medical help:

• The criteria for when to reconsult are adapted from the admission criteria in the National Institute for Health and Clinical Excellence guidance Feverish illness in children. Assessment and initial management in children younger than 5 years. These criteria are based upon evidence from a number of cohort studies, that have reported on the relationship between individual symptoms, signs, and a combination of symptoms and signs, in predicting the likely presence of serious illness in a child with fever [NICE, 2007].

Basis for recommendations on management of future episodes:

• Viral-induced wheeze (also called episodic wheeze) is a distinct diagnosis from asthma, and the wheeze is caused by a different underlying mechanism. Viral-induced wheeze only occurs in association with infection, and generally only in children between 6 months and 5 years of age. Viral-induced wheeze generally declines over time, usually, but not always, disappearing by the age of 6 years [Brand et al, 2008].
• In children with mild, intermittent wheeze and other respiratory symptoms which occur only with viral upper respiratory infections (colds), it is often reasonable to give no specific treatment and to plan a review of the child after an interval agreed with the parents or carers [SIGN and BTS, 2008].
• Although a trial of therapy with inhaled or oral corticosteroids is widely used to help make a diagnosis of asthma, there is little objective evidence to support this approach in children with recurrent wheeze [SIGN and BTS, 2008]. In addition, it can be difficult to assess the response to treatment as an improvement in symptoms or lung function may be due to spontaneous remission.
• In children with viral-associated wheeze who have responded to bronchodilator therapy, it seems reasonable to prescribe a bronchodilator for use during future episodes.