Management of wheezing in preschool children: ERAS Group guidelines

Recommendation 1. The distinction between episodic viral wheezing (EVW) and multiple trigger wheezing (MTW) is useful for the therapeutic strategy but should be periodically reassessed as it may change over time. The choice between montelukast and inhaled corticosteroids (ICS), and between daily or intermittent therapy should take into account the wheezing phenotype (EVW or MTW), the severity of symptoms, and family history.

Recommendation 2. Inhaled short-acting β2-agonists (SABA) represent the first-line treatment in preschool children with asthma-like symptoms. In the case of a mild-to-moderate wheezing attack, a pressurized metered-dose inhaler (pMDI) with a spacer is preferred over nebulization in children under 2 years of age. Nebulization driven by oxygen should be reserved for severe attacks.

Recommendation 3. A course of OCS is not routinely recommended in preschool children with acute wheezing attacks, but it can be considered in the case of severe wheezing exacerbation that requires access to the emergency department or requires hospitalization.

Recommendation 4. In preschool children with EVW but symptoms that are not persistent, intermittent therapy with high dose ICS could be used for 7–10 days at the first sign of respiratory infection.

Recommendation 5. Antibiotics are not recommended for exacerbation of preschool wheezing.

Recommendation 6. Nebulization with ipratropium bromide is not recommended in the exacerbation of preschool wheezing.

Recommendation 7. Leukotriene receptor antagonist (LTRA) are not recommended in exacerbation of preschool wheezing.

Recommendation 8. In preschool children with persistent or recurrent wheezing and in those with severe exacerbations, daily controller therapy with daily ICS should be started.

Recommendation 9. ICS is recommended as a first choice as controller therapy in preschool children with wheezing, but montelukast could be considered in case of a lack of cooperation or poor compliance.

Recommendation 10. Although there is no clear evidence regarding the ideal duration of treatment, in children with recurrent wheezing, controller therapy with ICS should be continued for at least 3 months. In case of good symptom control, the clinician can make an attempt to suspend the daily treatment and then reassess the child in the short term.

Recommendation 11. In preschool children with recurrent or persistent wheezing, treatment with intermittent high dose ICS for 7–10 days at first signs of respiratory infection or daily ICS as controller therapy are both recommended to reduce the risk of wheezing exacerbations. A follow-up of the patient after 3 months is recommended to re-assess the clinical picture and the therapy.

Recommendation 12. Clinical effects of montelukast can be evident within a few weeks, but in case of its use, a 3-month trial is suggested. If the child shows no response to this treatment, montelukast should be discontinued.

"Undoubtedly, more research is needed to find objective biomarkers and understand underlying mechanisms to assess phenotype and endotype and to personalize targeted treatment," the authors wrote.

Reference:

Fainardi V, Caffarelli C, Deolmi M, Skenderaj K, Meoli A, Morini R, Bergamini BM, Bertelli L, Biserna L, Bottau P, Corinaldesi E, De Paulis N, Dondi A, Guidi B, Lombardi F, Magistrali MS, Marastoni E, Pastorelli S, Piccorossi A, Poloni M, Tagliati S, Vaienti F, Gregori G, Sacchetti R, Mari S, Musetti M, Antodaro F, Bergomi A, Reggiani L, Caramelli F, De Fanti A, Marchetti F, Ricci G, Esposito S; Emilia-Romagna Asthma (ERA) Study Group. Management of Preschool Wheezing: Guideline from the Emilia-Romagna Asthma (ERA) Study Group. J Clin Med. 2022 Aug 15;11(16):4763. doi: 10.3390/jcm11164763. PMID: 36013002; PMCID: PMC9409690.