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Treatment for Children with Viral-Induced Wheeze

Treatment with oral or inhaled corticosteroids is not warranted for children without history of atopy or family history of asthma, but medium-dose inhaled corticosteroids or leukotriene inhibitors might be warranted in children who seem to be at risk for asthma.

Children with viral-induced wheeze often receive oral or inhaled corticosteroids or a leukotriene inhibitor despite a lack of good evidence that they work. Three studies shed light on this condition.

In a double-blind, randomized trial, 220 children (age range, 1–5 years) who had histories of intermittent wheeze associated with respiratory tract infection (RTI) received albuterol plus a 7-day course of inhaled budesonide (1000 µg twice daily), montelukast (4000 µg daily), or placebo at the onset of each RTI. The three groups had similar proportions of episode-free days during 12 months of treatment (the primary outcome; about 75%), oral steroid use, and healthcare utilization. However, during the 14 days after initiation of the study drug, children who received inhaled budesonide or montelukast had significant reductions in total symptom scores (reflecting wheeze, cough, and activity level). Children who were considered at high risk for asthma at baseline received the greatest benefit from the study medications.

In another double-blind, randomized, 12-month trial, 127 children (age range, 1–6 years) with histories suggestive of viral-induced wheeze received high-dose fluticasone (750 µg twice daily) or placebo at the onset of each RTI and continued until 48 hours after they were symptom free. If symptoms worsened, parents administered two to four inhalations of albuterol (100 µg). Children whose symptoms lasted more than 10 days received medical consultation. Rescue oral steroids were required in significantly more episodes of RTI in the placebo group than in the fluticasone group (18% vs. 8%), and fluticasone-treated children had significantly shorter symptom duration (about 1–2 days). However, fluticasone recipients gained significantly less weight (mean, 1.53 kg vs. 2.17 kg) and height (mean, 6.23 cm vs. 6.56 cm) than placebo recipients.

In a third randomized trial, 687 children (age range, 10 months – 5 years) who were hospitalized in three U.K. hospitals with viral infection–associated wheezing and did not respond to albuterol received a 5-day course of once-daily oral prednisolone or placebo. No differences between groups emerged for the primary outcome of time to discharge from the hospital or for the secondary outcomes of number of albuterol administrations during hospitalization and respiratory scores at 4, 12, and 24 hours.

Comment: An editorialist argues strongly that no role exists for oral steroids in preschool children with viral-induced wheezing and no history of atopy. He warns that the reduced growth associated with high-dose fluticasone use is concerning, particularly in the 10% of children who have 10 or more RTIs per year and could receive large cumulative doses. Based on the data in the first study, he suggests that leukotriene antagonists might be beneficial. Where does this leave us for treatment of children with viral-induced wheezing? For children who have no history of atopy and no family history of asthma, treatment with oral steroids or inhaled corticosteroids is not warranted. However, for children who seem to be at risk for asthma (positive family history, atopy), either medium-dose inhaled corticosteroids or a leukotriene inhibitor might be warranted during an RTI.

— Howard Bauchner, MD

Published in Journal Watch Pediatrics and Adolescent Medicine January 21, 2009

Citation(s):

Bacharier LB 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 Dec; 122:1127.

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Ducharme FM et al. Preemptive use of high-dose fluticasone for virus-induced wheezing in young children. N Engl J Med 2009 Jan 22; 360:339.

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Panickar J et al. Oral prednisolone for preschool children with acute virus-induced wheezing. N Engl J Med 2009 Jan 22; 360:329.

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Bush A. Practice imperfect — Treatment for wheezing in preschoolers. N Engl J Med 2009 Jan 22; 360:409.

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• Medline abstract (Free)