Paeds · respiratory-sleep-and-airway
Recurrent wheeze in preschool children
Also known as Preschool wheeze · Episodic viral wheeze · Multiple-trigger wheeze · Viral-induced wheeze · Wheezy toddler
Fellowship guide to recurrent wheeze in preschool children: the phenotype framework (episodic viral versus multiple-trigger wheeze), the Asthma Predictive Index and atopy as the risk stratifier, the small-airway and inflammatory pathophysiology, the bedside assessment that separates wheeze from mimics, the acute and preventive management with the pivotal randomised trials (PEAK, MIST, Ducharme, Bacharier, Panickar), and the natural history that lets most children outgrow it.
On this page
Study tools
Your progress
Saved on this device.
Practise this topic
Target exams
Red flags
- Wheeze that dates from the first days of life, is monophonic or fixed, or is associated with feeding difficulty, stridor, or failure to thrive suggests a structural or aspiration cause (vascular ring, tracheobronchomalacia, laryngeal cleft) — not preschool wheeze — and needs imaging and airway assessment
- A preschool child in a severe or life-threatening acute attack — silent chest, exhaustion, cyanosis, SpO2 below 92% on air, or altered consciousness — needs immediate burst bronchodilator, systemic corticosteroid, oxygen, and senior/retrieval involvement, never a wait-and-see trial
- Failure to thrive, chronic wet cough, finger clubbing, or a wheeze that never fully clears points away from simple preschool wheeze toward cystic fibrosis, primary ciliary dyskinesia, bronchiectasis, or immunodeficiency and mandates specialist investigation
- A sudden monophonic wheeze of abrupt onset in a well toddler, especially after a choking episode, is an inhaled foreign body until proven otherwise and requires urgent bronchoscopy regardless of a normal chest radiograph
Life stages
Care settings
Clinical exam formats
Board mappings
- Recurrent wheeze in preschool children
- Preschool wheeze: phenotypes, prediction, and pharmacotherapy
- Preschool wheeze: episodic viral versus multiple-trigger, and the evidence for ICS
- Long case: the recurrently wheezy preschooler
- Short case: respiratory examination of the wheezy child
- Wheeze in the preschool child
- Preschool wheeze: phenotypes, prediction, and management
- Respiratory: the wheezy preschool child
- Pulmonology: recurrent wheeze and early-childhood asthma
- Patient Care: recurrent wheeze in the young child
- Medical Expert: preschool wheeze and early asthma
Overview & Definition
Watch a two-year-old with a cold and you will often hear it: a high-pitched, musical, expiratory whistle that comes and goes with each viral illness, then vanishes when the child is well. Wheeze is that continuous musical sound generated by turbulent airflow through narrowed intrathoracic airways, and in the preschool years it is one of the commonest reasons a family brings a child to a doctor. The task the clinician faces is not to hear the wheeze — parents already report it — but to decide what it means and what, if anything, to do about it. [2]
Recurrent wheeze in preschool children is a descriptive label, not a diagnosis. It covers the child under six years with repeated episodes of wheeze, and it deliberately avoids the word "asthma" because most of these children will never have persistent asthma. The landmark Tucson cohort of Martinez and colleagues reframed the whole field by showing that early wheeze is a mix of quite different trajectories, most of which remit, and only a minority of which represent early atopic asthma. Getting the frame right — phenotype and trajectory, not a single disease — is the whole point of the topic. [1] [2]
References9ShowHide
- [1]Martinez FD; Wright AL; Taussig LM; Holberg CJ; Halonen M; Morgan WJ Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med, 1995.PMID 7800004
- [2]Brand PL; Baraldi E; Bisgaard H; Boner AL; Castro-Rodriguez JA; Custovic A; et al Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J, 2008.PMID 18827155
- [3]Castro-Rodríguez JA; Holberg CJ; Wright AL; Martinez FD A clinical index to define risk of asthma in young children with recurrent wheezing. Am J Respir Crit Care Med, 2000.PMID 11029352
- [4]Guilbert TW; Morgan WJ; Zeiger RS; Mauger DT; Boehmer SJ; Szefler SJ; et al Long-term inhaled corticosteroids in preschool children at high risk for asthma. N Engl J Med, 2006.PMID 16687711
- [5]Ducharme FM; Lemire C; Noya FJ; Davis GM; Alos N; Leblond H; et al Preemptive use of high-dose fluticasone for virus-induced wheezing in young children. N Engl J Med, 2009.PMID 19164187
- [6]Bacharier LB; Phillips BR; Zeiger RS; Szefler SJ; Martinez FD; Lemanske RF Jr; et al Episodic use of an inhaled corticosteroid or leukotriene receptor antagonist in preschool children with moderate-to-severe intermittent wheezing. J Allergy Clin Immunol, 2008.PMID 18973936
- [7]Zeiger RS; Mauger D; Bacharier LB; Guilbert TW; Martinez FD; Lemanske RF Jr; et al Daily or intermittent budesonide in preschool children with recurrent wheezing. N Engl J Med, 2011.PMID 22111718
- [8]Panickar J; Lakhanpaul M; Lambert PC; Kenia P; Stephenson T; Smyth A; et al Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med, 2009.PMID 19164186
- [9]Brand PL; Caudri D; Eber E; Gaillard EA; Garcia-Marcos L; Hedlin G; et al Classification and pharmacological treatment of preschool wheezing: changes since 2008. Eur Respir J, 2014.PMID 24525447