Wheezing in Infants and Children

It is very common for infants and children to be taken to the paediatrician’s office to evaluate a cough. When the child’s body fights an infection and turns on the immune system, mucus is produced, as part of the defense against the infection, and the body removes the mucus from the airways through the cough.

Sometimes, a “wheeze” is found when the child’s breathing is examined with the stethoscope. This term is used to describe the noise caused by airflow when the child is breathing out (exhaling) that occurs when the inflammation in the lower airways and the accompanying spasm of small muscles surrounding the smallest airways encroaches on the airway diameter and increases resistance to air flow.

This type of inflammation can be caused by an infection (typically with viruses, including the common respiratory viruses, and in particular the “Respiratory Syncytial Virus” or “RSV”) and can be aggravated – predominantly in older children – by allergies, exercise and cold temperatures.

We will often treat children who wheeze with medications supplied in MDAs (“metered dose aerosols” or “puffers”) that relax the airway muscles (Ventolin®, salbutamol, blue puffer, a “beta-agonist”) and decrease the inflammation (Flovent®, fluticasone, orange puffer, an inhaled steroid).

We always prescribe an Aerochamber® with mask (for infants and younger children) or with mouthpiece (older children) to assure the effective inhalation of the medication. No matter how old or cooperative a patient is, puffers should always be used with an aerochamber. In older children and teenagers, other treatment modalities (Turbohaler®, Diskhaler®) can be prescribed.

We typically will start infants and children on a regime of puffers that uses the blue puffer every four hours while the patient is awake and the orange puffer every 12 hours.

In the morning and in the evening, two puffs of Ventolin® (blue puffer) are followed by two puffs of Flovent® (orange puffer). Please rinse out the child’s mouth after using the orange puffer to prevent oral thrush (a rare complication of inhaled fluticasone when the mouth is not rinsed out after use of the orange puffer).

During the day, Ventolin® (blue puffer) is initially administered every four hours, two puffs each time (usually twice between the morning and evening dose of both puffers). Once symptoms have improved, the use of the blue puffer may be reduced to twice daily, before the use of the orange puffer.

In the alphabet, “B” for “blue” comes before “O” for “orange”. Likewise, when both puffers are being used, the blue puffer is always used before the orange puffer.

Once the child’s cough has subsided, you may discontinue the use of Ventolin® (blue puffer) suddenly and without taper; after Ventolin (blue puffer) is stopped, Flovent (orange puffer) is usually continued for another week at the same dose (two puffs twice daily) and then decreased to one puff twice daily for another week, before it is discontinued. Some children require an even slower taper. Do not discontinue Flovent without taper.

When the airways are particularly tight and inflamed and the wheezing is severe, we sometimes will prescribe an oral steroid to speed up the improvement (Dexamethasone, typically one single dose by mouth, or Prednisone, once daily for 5 days).

In children with chronic wheezing, an oral medication, Singulair®, can be prescribed to decrease the chronic use of inhaled steroids (“steroid sparing effect”).

You should restart the medication when your child starts to cough and wheeze again before you see the doctor, as the anti-inflammatory effect of the medication is most effective if started early in the course of the illness.

Please make sure to ask us any questions you may have!