Pediatric Asthma & Wheezing
Match the inhaler to the age, rescue the attack, and unmask the wheeze that isn't asthma
Recognizing asthma in children
The pattern. Asthma is chronic airway inflammation with variable, reversible obstruction. Children have recurrent cough (often at night or with exercise), wheeze, chest tightness, and shortness of breath triggered by viral infections, exercise, cold air, allergens, or tobacco smoke, often alongside eczema, allergic rhinitis, or a family history of atopy.
Confirming it. From about age 5, spirometry shows obstruction that reverses: FEV1 rises by at least 12% after inhaled albuterol. Younger children cannot perform reliable spirometry, so the diagnosis rests on the history and on response to a therapeutic trial.
Assessing control. At every visit ask about daytime symptoms, night waking, reliever use, activity limits, and oral-steroid courses. Symptoms or SABA use on more than 2 days a week, any regular night waking, limits on play or sport, or repeated steroid bursts mean the asthma is not well controlled.
Controller therapy by age
| Step | Ages 0–4 | Ages 5–11 |
|---|---|---|
| 1 | As-needed SABA; add a short daily ICS course at the onset of each viral illness for recurrent viral wheeze | As-needed SABA |
| 2 | Daily low-dose ICS | Daily low-dose ICS |
| 3 | Daily medium-dose ICS | Low-dose ICS-formoterol, daily and as needed (SMART) |
| 4 | Medium-dose ICS plus a LABA or montelukast | Medium-dose ICS-formoterol SMART |
| 5–6 | High-dose ICS-LABA, then oral corticosteroid | High-dose ICS-LABA; oral corticosteroid or a biologic such as omalizumab; specialist care |
Children under 5. Many preschoolers wheeze only with colds. For them, give as-needed SABA plus a short course of daily inhaled corticosteroid (ICS) started at the first sign of each respiratory infection. Frequent or persistent symptoms call for daily low-dose ICS, delivered by nebulized budesonide or an MDI with a valved spacer and face mask.
SMART. Single maintenance and reliever therapy uses one ICS-formoterol inhaler (for example, budesonide-formoterol) both daily and whenever symptoms occur, so each rescue dose also delivers anti-inflammatory steroid. It works because formoterol acts within minutes. Salmeterol is slow in onset, so it is never a reliever and is never given without an ICS.
Montelukast is an alternative controller but carries a boxed warning for neuropsychiatric effects: agitation, nightmares, depression, and suicidal thinking.
Before stepping up. Most poor control is fixable. Watch the child use the device (MDI with a valved spacer, plus a mask under about age 4), review adherence, reduce triggers (tobacco smoke, dust mites, pets, cockroaches, mold), and treat allergic rhinitis, GERD, and obesity. A spacer increases lung deposition and reduces oropharyngeal ICS deposition that causes thrush and hoarseness; rinse and spit after each dose. After about 3 months of good control, step down to the lowest effective dose.
Every child. Provide a written asthma action plan with green (daily care), yellow (worsening: increase reliever, call), and red (emergency) zones, and give a yearly inactivated influenza vaccine. The live nasal vaccine is avoided in children aged 2–4 who have wheezed in the past year.
Treating an exacerbation
- Bronchodilatealbuterol by MDI-spacer or nebulizer every 20 minutes for 3 doses; add ipratropium in moderate–severe attacks during the first hour to reduce admissions
- Oxygenfor hypoxemia
- Steroid within the first houroral dexamethasone 0.6 mg/kg for 1–2 doses, or prednisolone 1–2 mg/kg/day for 3–5 days; oral works as well as IV
- Still severe after an hourIV magnesium sulfate, about 50 mg/kg (max 2 g); it relaxes bronchial smooth muscle and can cause hypotension and flushing
- Refractorycontinuous albuterol, IV terbutaline, high-flow nasal cannula or noninvasive ventilation in the PICU; intubation is a last resort, with ketamine for induction
Impending respiratory failure: a silent chest (too little airflow to wheeze), drowsiness or confusion, exhaustion, inability to speak, paradoxical breathing, cyanosis, bradycardia, and a normal or rising PCO2. A tachypneic child should be hypocapnic, so a PCO2 of about 40 or higher means the child is tiring. Move to the PICU and prepare for ventilatory support.
What not to do. Chest X-ray and antibiotics are not routine; image only for focal findings, suspected pneumothorax or pneumonia, or a possible foreign body. On discharge, complete the steroid course, start or step up a controller, review the action plan, and arrange early follow-up.
When the wheeze is not asthma
| Condition | Clues | Next step |
|---|---|---|
| Bronchiolitis | First wheeze under age 2, rhinorrhea prodrome, winter RSV | Supportive care; oxygen if SpO2 <90% |
| Foreign-body aspiration | Age 1–3, choking spell, unilateral wheeze or decreased breath sounds | Expiratory or decubitus films; rigid bronchoscopy |
| Laryngomalacia | Inspiratory stridor from the first weeks, worse supine, better prone | Flexible laryngoscopy; observation |
| Vascular ring | Biphasic stridor, dysphagia, worse with feeds, neck hyperextension | Barium esophagram, CT or MR angiography, surgery |
| Cystic fibrosis | Failure to thrive, greasy stools, recurrent pneumonia | Sweat chloride test |
| GERD | Regurgitation, cough or wheeze at night | Treat reflux |
| Heart failure | Sweating with feeds, hepatomegaly, murmur or gallop (left-to-right shunt) | Echocardiogram |
Bronchiolitis. Peak age 2–6 months; a runny-nose prodrome precedes tachypnea, retractions, crackles, and wheeze. The diagnosis is clinical, and care is supportive (nasal suctioning, hydration, oxygen below 90%) without routine albuterol, steroids, antibiotics, or X-rays. Nirsevimab for the infant, or RSV vaccination of the mother during pregnancy, prevents severe disease.
Foreign-body aspiration. Peaks at ages 1–3, typically with nuts or other food, after a sudden choking or coughing spell that may be unwitnessed. Most objects are radiolucent, so look for air trapping: the obstructed lung stays hyperinflated on an expiratory film or when it is the dependent side on a lateral decubitus film. A convincing history mandates rigid bronchoscopy, which is diagnostic and therapeutic, even when films are normal; a retained object causes recurrent pneumonia and bronchiectasis. For complete obstruction in a conscious child, give back blows and chest thrusts under age 1 and back blows alternating with abdominal thrusts from age 1 (AHA 2025), and never perform blind finger sweeps.
Laryngomalacia. The most common cause of stridor in infants. Floppy supraglottic tissue (an omega-shaped epiglottis, prolapsing arytenoids) collapses on inspiration, starting in the first weeks of life and worsening with crying, feeding, or lying supine. Flexible laryngoscopy confirms it. Most cases resolve by 12–18 months; supraglottoplasty is reserved for failure to thrive, apnea, or cyanosis.
Vascular ring. A double aortic arch (most common) or a right aortic arch with a ligamentum arteriosum encircles the trachea and esophagus. Stridor is biphasic or the wheeze is fixed and unresponsive to bronchodilators; feeding worsens it, and dysphagia, vomiting, recurrent infections, and neck hyperextension are typical. A barium esophagram shows a posterior indentation, CT or MR angiography defines the anatomy, and surgery divides the ring.
All that wheezes is not asthma: focal, persistent, or bronchodilator-unresponsive wheeze, or wheeze with failure to thrive, demands a search for another cause.