Wheezing in infants and toddlers: we still don’t know what’s best to do

The winter virus season is fast approaching, bringing with it the old dilemma of what to do about infants and toddlers who wheeze. Last year I noted that we had no specific treatment that worked.

A few months after my post, investigators in Canada published a large study that compared two of the standard treatments traditionally used for wheezing infants and toddlers: oral steroids and nebulized (inhaled) epinephrine (or albuterol). The randomized, placebo-controlled study compared children who came to the emergency department for breathing difficulties. They received either, both, or none of those therapies. The endpoint the researchers studied was how many of those children progressed to get sick enough to need admission to the hospital during the subsequent week.

The results showed that maybe — maybe — there was a slight beneficial effect of both treatments together in keeping kids out of the hospital, but neither treatment alone helped. An accompanying editorial in the same issue pointed out the problem here: when infants and toddlers come with their first episode (or episodes) of wheezing, we don’t know if they are going to continue to have problems in the future (such as progressing to asthma) or not. These treatments clearly help asthma. So if we give them to all comers with wheezing symptoms there will be some, those who are destined to have asthma later, who will benefit. But that’s not at all the same thing as saying that these treatments (which are not risk-free) will help kids with bronchiolitis, by far the most common cause of wheezing in this age group.

Over the past year the authors of the study, probably a bit stung by the pooh-poohing of their findings, have churned through their data from a different angle. This sort of data-mining in search of positive findings is common, especially if the original findings were not earth-shaking (or even useful). After all, people’s careers in academic medicine may be at stake. Anyway, they’ve just published an article on the cost-effectiveness of of using the combination of inhaled epinephrine and oral steroids. They conclude that these therapies, which medically don’t help much, still save a little money — to society, not necessarily to the family. I don’t find that argument convincing, either.

So what do most of us do with wheezing infants and toddlers, especially those who have bronchiolitis? I think most of us give a trial of the inhaled medicine to see if it helps. If it does, we continue it; if it doesn’t, we don’t. If there is dramatic improvement with the inhaled medicine, we consider giving the steroids. The presumption is that kids who respond dramatically to the inhaled medicine are more likely to become asthmatic, so what we are really doing is treating early asthma, not bronchiolitis.

As a parent, what this controversy means to you is that the correct answer is still unknown, although the preponderance of expert opinion is that bronchiolitis — wheezing in small children — requires supportive care, such as help with feeding, clearance of respiratory mucous, and sometimes oxygen, but there are no good data showing the benefit of anything else.