Recurrent wheeze in a preschooler: when to start a preventer
A 3-year-old boy attends with his mother because of recurrent wheeze. He has had seven episodes in the past 12 months, each beginning with a coryza and lasting 5–7 days. Between episodes he is well, runs without limitation, and has no night cough. He has eczema on his flexures and his mother has asthma; his father smokes indoors. Examination today: chest clear, respiratory rate 24, oxygen saturation 98% in air, no recession, no clubbing, growth on the 50th centile. He has received two courses of oral prednisolone in the last year, both from an out-of-hours service, and has never been admitted. He uses a salbutamol inhaler with a spacer when symptomatic, and his mother reports definite benefit. He has no regular preventer. You are asked to review him in a community clinic.
1. Does this child have asthma, and how would you manage him at this consultation? Explain your reasoning.
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Yes, this is likely asthma, but the label matters less than the pattern and the response. Preschool wheeze is heterogeneous: episodic viral wheeze is common and often remits, whereas multi-trigger wheeze and atopy predict persistence. This child has had seven episodes, two requiring oral steroids, eczema, and maternal asthma, so his Asthma Predictive Index is positive and his risk of ongoing symptoms is appreciable. Spirometry is unreliable at 3 years, so I would make a clinical diagnosis and document bronchodilator responsiveness.
At this visit I would: (1) start a daily low-dose inhaled corticosteroid via a spacer with a well-fitted mask for a 3-month trial; (2) check and demonstrate inhaler technique; (3) give a written asthma action plan and safety-net advice; (4) address paternal indoor smoking, which increases exacerbations; and (5) review in 3 months with a symptom diary rather than relying on a single clinic visit.
2. At review 3 months later, what findings would make you continue, step down, or refer?
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At 3 months I would compare exacerbation frequency, night symptoms, reliever use, and any unscheduled care. If he has had fewer episodes, no night cough, and no steroid courses, continue the same low dose and review in 6 months, stepping down after 6–12 months of stability.
If symptoms are unchanged, the trial has failed: stop the ICS rather than escalating blindly, reassess for alternative diagnoses, and reconsider whether episodes are purely viral. If he has had another severe exacerbation, persistent interval symptoms, or poor growth, refer to paediatric respiratory for lung function when old enough, allergy assessment, and consideration of a higher dose or specialist review. I would also check adherence and technique before changing treatment, because apparent non-response is often due to poor spacer use or ongoing smoke exposure. The decision is based on the pattern over time, not on one normal examination.