Indian J Pediatr (October 2015) 82(10):971–972 DOI 10.1007/s12098-015-1749-8
CORRESPONDENCE
Preschool Wheeze is Not Asthma: A Clinical Dilemma – Authors’ Reply Siba Prosad Paul 1 & Jayesh M. Bhatt 2
Received: 3 March 2015 / Accepted: 16 March 2015 / Published online: 22 May 2015 # Dr. K C Chaudhuri Foundation 2015
To the Editor: We thank the commentators for their interest in our article entitled ‘Preschool wheeze is not asthma: a clinical dilemma’ [1] and the comments they have made regarding the condition. Wheeze is a common symptom in children and it is important that the clinicians confirm what the parents actually mean by wheeze [1, 2]. The commentators have highlighted an increasing incidence of preschool wheezing in children, however, it is important to note that this may vary according to the criteria that were used to define the episodes. A prevalence study involving children aged 1 to 5 y from the USA and Europe found that one-third of the children suffered from recurrent asthma-like symptoms [3]. Another study in the UK amongst preschool children aged 1 to 4 y described the prevalence of recurrent wheezing (one or more episodes) in 1-yold children was 25.5 % in South Asians and 35.6 % in white infants [4]. An international consensus group has acknowledged that since the release of the European Respiratory Society Task Force report on preschool wheeze in 2008, significant new evidence has become available and proposed some modifications to the earlier recommendations [5]. The consensus group acknowledges that the distinction between episodic viral wheeze (EVW) and multiple-trigger wheeze (MTW) may be unclear in many patients and that the wheeze patterns in young
* Siba Prosad Paul [email protected] 1
Department of Pediatric Gastroenterology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
2
Department of Pediatric Respiratory Medicine, Nottingham Children’s Hospital, Nottingham, UK
children will vary over time and with treatment [5]. They also suggest that in EVW with frequent or severe episodes, or when the clinician suspects that interval symptoms are being under reported, inhaled corticosteroid therapy may be used. This is somewhat in line with the suggestions made by the commentators. However, in the absence of an international consensus on the terminology it may not be appropriate to use a blanket terminology such as ‘early wheezer’. The commentators have tried to oversimplify the spectrum of conditions (bronchiolitis, preschool wheeze, early-onset asthma) which present with wheeze in early childhood. These are not the same entity as bronchiolitis caused by respiratory syncytial virus in infants predisposes them to episodes of further recurrent wheeze [6]. However, the wheezing that occurs during bronchiolitis cannot be classed as the first episode of viral wheeze. Similarly, early onset asthma is predominantly an eosinophilic disease while EVW showed predominance of neutrophils on broncho-alveolar lavage [7]. The commentators further suggest MTW may develop into asthma, hence ‘atopic multitrigger wheeze’ is an important phenotype, this is similar to the two phenotypes of wheeze (atopic persistent wheeze, transient viral wheeze) identified from two independent cohorts by Spycher, et al [8]. The consensus statement released in 2014 still identified preschool as a separate entity and diagnosing asthma in young children remains a challenge and should be decided on an individual basis and generalization is not suggested. The pharmacological therapies used in preschool wheeze are not disease modifying agents and are primarily aimed at symptomatic relief and improving quality of life for the child. This should be clearly explained to parents at the initiation of the therapy for preschool wheeze and early discontinuation of treatment is necessary if no benefit is evident [5]. While the commentators have raised some valid points, their emphasis on oversimplifying the spectrum of conditions is likely to lead
972
Indian J Pediatr (October 2015) 82(10):971–972
to overuse of inhaled and systemic corticosteroids and largely defeats the purpose of labeling preschool wheeze as an entity which is not asthma! Further research and epidemiological studies are necessary to improve classification and management.
3. 4.
5. Conflict of Interest None. Source of Funding None. 6.
References 7. 1. 2.
Paul SP, Bhatt JM. Preschool wheeze is not asthma: a clinical dilemma. Indian J Pediatr. 2014;81:1193–5. Lowe L, Murray CS, Martin L, Deas J, Cashin E, Poletti G, et al. Reported versus confirmed wheeze and lung function in early life. Arch Dis Child. 2004;89:540–3.
8.
Bisgaard H, Szefler S. Prevalence of asthma-like symptoms in young children. Pediatr Pulmonol. 2007;42:723–8. Kuehni CE, Strippoli MP, Low N, Brooke AM, Silverman M. Wheeze and asthma prevalence and related health-service use in white and south Asian pre-school children in the United Kingdom. Clin Exp Allergy. 2007;37:1738–46. 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;43: 1172–7. Zomer-Kooijker K, van der Ent CK, Ermers MJ, Uiterwaal CS, Rovers MM, Bont LJ; RSV Corticosteroid Study Group. Increased risk of wheeze and decreased lung function after respiratory syncytial virus infection. PLoS One. 2014;9:e87162. Oommen A, Patel R, Browning M, Grigg J. Systemic neutrophil activation in acute preschool viral wheeze. Arch Dis Child. 2003;88:529–31. Spycher BD, Silverman M, Pescatore AM, Beardsmore CS, Kuehni CE. Comparison of phenotypes of childhood wheeze and cough in 2 independent cohorts. J Allergy Clin Immunol. 2013;132:1058–67.
CORRESPONDENCE
Preschool Wheeze is Not Asthma: A Clinical Dilemma – Authors’ Reply Siba Prosad Paul 1 & Jayesh M. Bhatt 2
Received: 3 March 2015 / Accepted: 16 March 2015 / Published online: 22 May 2015 # Dr. K C Chaudhuri Foundation 2015
To the Editor: We thank the commentators for their interest in our article entitled ‘Preschool wheeze is not asthma: a clinical dilemma’ [1] and the comments they have made regarding the condition. Wheeze is a common symptom in children and it is important that the clinicians confirm what the parents actually mean by wheeze [1, 2]. The commentators have highlighted an increasing incidence of preschool wheezing in children, however, it is important to note that this may vary according to the criteria that were used to define the episodes. A prevalence study involving children aged 1 to 5 y from the USA and Europe found that one-third of the children suffered from recurrent asthma-like symptoms [3]. Another study in the UK amongst preschool children aged 1 to 4 y described the prevalence of recurrent wheezing (one or more episodes) in 1-yold children was 25.5 % in South Asians and 35.6 % in white infants [4]. An international consensus group has acknowledged that since the release of the European Respiratory Society Task Force report on preschool wheeze in 2008, significant new evidence has become available and proposed some modifications to the earlier recommendations [5]. The consensus group acknowledges that the distinction between episodic viral wheeze (EVW) and multiple-trigger wheeze (MTW) may be unclear in many patients and that the wheeze patterns in young
* Siba Prosad Paul [email protected] 1
Department of Pediatric Gastroenterology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol BS2 8BJ, UK
2
Department of Pediatric Respiratory Medicine, Nottingham Children’s Hospital, Nottingham, UK
children will vary over time and with treatment [5]. They also suggest that in EVW with frequent or severe episodes, or when the clinician suspects that interval symptoms are being under reported, inhaled corticosteroid therapy may be used. This is somewhat in line with the suggestions made by the commentators. However, in the absence of an international consensus on the terminology it may not be appropriate to use a blanket terminology such as ‘early wheezer’. The commentators have tried to oversimplify the spectrum of conditions (bronchiolitis, preschool wheeze, early-onset asthma) which present with wheeze in early childhood. These are not the same entity as bronchiolitis caused by respiratory syncytial virus in infants predisposes them to episodes of further recurrent wheeze [6]. However, the wheezing that occurs during bronchiolitis cannot be classed as the first episode of viral wheeze. Similarly, early onset asthma is predominantly an eosinophilic disease while EVW showed predominance of neutrophils on broncho-alveolar lavage [7]. The commentators further suggest MTW may develop into asthma, hence ‘atopic multitrigger wheeze’ is an important phenotype, this is similar to the two phenotypes of wheeze (atopic persistent wheeze, transient viral wheeze) identified from two independent cohorts by Spycher, et al [8]. The consensus statement released in 2014 still identified preschool as a separate entity and diagnosing asthma in young children remains a challenge and should be decided on an individual basis and generalization is not suggested. The pharmacological therapies used in preschool wheeze are not disease modifying agents and are primarily aimed at symptomatic relief and improving quality of life for the child. This should be clearly explained to parents at the initiation of the therapy for preschool wheeze and early discontinuation of treatment is necessary if no benefit is evident [5]. While the commentators have raised some valid points, their emphasis on oversimplifying the spectrum of conditions is likely to lead
972
Indian J Pediatr (October 2015) 82(10):971–972
to overuse of inhaled and systemic corticosteroids and largely defeats the purpose of labeling preschool wheeze as an entity which is not asthma! Further research and epidemiological studies are necessary to improve classification and management.
3. 4.
5. Conflict of Interest None. Source of Funding None. 6.
References 7. 1. 2.
Paul SP, Bhatt JM. Preschool wheeze is not asthma: a clinical dilemma. Indian J Pediatr. 2014;81:1193–5. Lowe L, Murray CS, Martin L, Deas J, Cashin E, Poletti G, et al. Reported versus confirmed wheeze and lung function in early life. Arch Dis Child. 2004;89:540–3.
8.
Bisgaard H, Szefler S. Prevalence of asthma-like symptoms in young children. Pediatr Pulmonol. 2007;42:723–8. Kuehni CE, Strippoli MP, Low N, Brooke AM, Silverman M. Wheeze and asthma prevalence and related health-service use in white and south Asian pre-school children in the United Kingdom. Clin Exp Allergy. 2007;37:1738–46. 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;43: 1172–7. Zomer-Kooijker K, van der Ent CK, Ermers MJ, Uiterwaal CS, Rovers MM, Bont LJ; RSV Corticosteroid Study Group. Increased risk of wheeze and decreased lung function after respiratory syncytial virus infection. PLoS One. 2014;9:e87162. Oommen A, Patel R, Browning M, Grigg J. Systemic neutrophil activation in acute preschool viral wheeze. Arch Dis Child. 2003;88:529–31. Spycher BD, Silverman M, Pescatore AM, Beardsmore CS, Kuehni CE. Comparison of phenotypes of childhood wheeze and cough in 2 independent cohorts. J Allergy Clin Immunol. 2013;132:1058–67.
