This infant was not given an asthma diagnosis or detailed asthma education/preventive care pending general pediatric follow-up to determine the recurrence of wheezing. The frequency of bronchiolitis in reaction to viral or bacterial infection for children younger than 2 years mitigates the likelihood of recurrent respiratory illness in this child. This conclusion is supported by his prompt response to antibiotics and bronchodilators.
Case 2. Acute therapy in this 2-year-old girl involved continued treatment with nebulized albuterol (1.25 mg every 4 hours) in the hospital plus intravenous prednisolone (2 mg/kg/d) and oral cefdinir (250 mg/d). She was discharged after 2 days.
Persistent asthma is more likely in this child, given her 1-month history of severe respiratory illness and atelectasis on the chest radiograph. Thus, the parents were instructed to continue her medications and follow up with the pulmonology clinic. The clinic prescribed therapy with an albuterol inhaler and spacer and provided parental asthma education. Note that her follow-up could also have been handled by the pediatric clinic; it was only because of time considerations that she was referred to pulmonology.
Given the suggestive radiographic findings and 1-month history of respiratory tract illness in the 2 patients described, it is important to follow up for recurrent symptoms and to urge cessation of smoking by family members. If symptoms continue to recur, then therapy will be based on whether the children are classified as having intermittent or persistent (mild/moderate/ severe) asthma. Poorly controlled disease warrants referral to pulmonology and/or allergy subspecialists for consideration of spirometry or skin testing for allergens.1 Follow-up is essential for classifying children with reactive airway disease and guiding long-term therapy.
For a complete discussion of how to assess asthma severity and tailor treatment regimens accordingly, see the 2-part series by Benjamin Tippets, DO, MPH, and Theresa W. Guilbert, MD, in CONSULTANT FOR PEDIATRICIANS on managing asthma in children.1,2
1. Tippets B, Guilbert TW. Managing asthma in children, part 1: making the
diagnosis, assessing severity. Consultant For Pediatricians. 2009;8:168-174.
2. Tippets B, Guilbert TW. Managing asthma in children, part 2: achieving and
maintaining control. Consultant For Pediatricians. 2009;8:221-227.
3. Strunk RC. Defining asthma in the preschool-aged child. Pediatrics. 2002;109
4. Plint AC, Johnson DW, Patel H, et al; Pediatric Emergency Research Canada
(PERC). Epinephrine and dexamethasone in children with bronchiolitis. N Engl
J Med. 2009;360:2079-2089.
5. American Academy of Pediatrics Subcommittee on Diagnosis and Management
of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118:
6. Gershel JC, Goldman HS, Stein RE, et al. The usefulness of chest radiographs
in first asthma attacks. N Engl J Med. 1983;309:336-339.