TLF -

Wheezing in
early life
DISCUSSION 1 -
DIAGNOSIS AND
DIFFERENTIAL
DIAGNOSES
 An educational initiative by
Abbott Nutrition

IMPORTANT NOTICE: MOTHER’S MILK IS BEST FOR THE

BABY

The content of this presentation is meant for the information

of Healthcare Professionals and Healthcare workers only.

Not intended for circulation.

 IMPORTANT NOTICE: MOTHER’S MILK IS BEST FOR
THE BABY
Breastfeeding provides the best nutrition and protection from illnesses of infants. For infants, breast milk is all that is needed for the first 6 months. Breastmilk is the best and most
economical food for baby.
Warning / Caution: Infant milk substitute is not the sole source of nourishment of an infant. Careful and hygienic preparation of infant milk substitute is most essential for health.
Lactose- free infant milk substitute should only be used in case of diarrehea due to Lactose intolerance. Lactose- free infant formula should be withdrawn, if there is no
improvement in symptoms of intolerance.
Continued use of infant milk substitute should not be recommended to avoid any difficulties in reverting to breastfeeding of infants after a period of feeding by infant milk substitute.
In the event recommending infant milk substitute in addition to breastmilk or its replacement during the first 6 months, keep the costs in mind before recommending use of infant
milk formula. Un-boiled water, un-boiled bottles or incorrect dilution can make a baby ill. Always advise to follow instructions exactly.
Unnecessary introduction of partial bottle-feeding or other foods and drinks will have negative effect on breastfeeding.
Characteristics of breastmilk : Immediately after delivery, breastmilk is yellowish and sticky. The milk is called Colostrum, which is secreted during the first-week of delivery.
Colostrum is more nutritious than mature milk because it contains more proteins, more anti-infective properties, which are of great importance for the infant’s defense against
dangerous neo-natal infections. It also contains higher levels of Vitamin ‘A’.
Advantages of breastfeeding : (A) Breastfeeding is much cheaper than feeding an infant milk substitute as the cost of extra food needed by the mother is negligible as compared to
cost of feeding infant milk substitute; (B) Breastmilk is always available; (C) Breastmilk needs no utensils or water (which might carry germs) or fuel for is preparation; (D) Mothers
who breastfeed usually have longer periods of infertility after child birth than non-lactators.
Management of breastfeeding, as under:
I. Breastfeeding
A. Immediately after delivery enables the contraction of the womb and helps the mother to regain her figure quickly.
B. Is successful when the infant suckles frequently and the mother wanting to breastfeed is confident in her ability to do so.
II.In order to promote and support breastfeeding the mother's natural desire to breastfeed should always be encouraged by giving, where needed,
practical advice and making sure that she has the support of her relatives.
iii. Adequate care for the breast and nipples should be taken during pregnancy.
iv. It is also necessary to put the infant to the breast as soon as possible after delivery.
v. Let the mother and the infant stay together after the delivery, the mother and her infant should be allowed to stay together (in hospital, this is called "rooming- in").
vi. Give the infant Colostrum as it is rich in many nutrients and its anti-infective factors protect the infants from infections during the few days of its birth.
vii. The practice of discarding Colostrum and giving sugar water, honey water, butter or other concoctions instead of Colostrum should be very strongly discouraged.
viii. Let the infants suckle on demand.
ix. Every effort should be made to breastfeed the infants whenever they cry.
x. mother should keep her body and clothes and that of the infant always neat and clean.
 Symptom assessment

Topics for Clinical evaluation and red flags

discussion
Differential diagnosis
 Although most do
not have an
Most infants
underlying serious
experience
illness, it is
wheezing at some
important to
point
identify those at
risk early

Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007 Feb;16(1):7-15. Review. PubMed PMID: 17297521; PubMed Central PMCID: PMC6634180.
Symptom assessment
Making a first impression
Common clinical presentation is a child with chronic and relatively non-specific symptoms such as
cough, “wheeze” and breathlessness
2. (Usually parental) over-anxiety, and
1. A normal child over interpretation of normal symptoms

5. A child with an ‘asthma 3. A child with a serious illness such as

syndrome’ cystic fibrosis, tuberculosis etc

4. Child with minor health issues which may cause asthma-like symptoms,
or co-exist with, and potentially worsen, an asthma syndrome

Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007 Feb;16(1):7-15. Review. PubMed PMID: 17297521; PubMed Central PMCID: PMC6634180.
Symptom assessment: Step-wise approach
If child makes respiratory noises, but does not have any breathlessness or
impairment of quality of life, does child have a problem?

Having established whether child truly wheezes and has excessive cough; the next
step is to identify pattern and severity of symptoms

Determine whether child has symptoms solely at time of a viral upper respiratory
infection or ‘cold’ (virus associated wheeze, or VAW), or whether there are
additional symptoms in between infections

If there are additional symptoms in between infections; symptom frequency and

triggers should be determined

Severity of symptoms should next be determined, both in terms of disruption to

child and family, in order to ensure that treatment is appropriately focused

Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007 Feb;16(1):7-15. Review. PubMed PMID: 17297521; PubMed Central PMCID: PMC6634180.
 A detailed history, targeted towards other respiratory
conditions is an essential first step in evaluating the
child with non-specific respiratory symptoms
Points to seek in the history suggesting an underlying serious diagnosis:

In general, the earlier the onset of symptoms, the more likely that an important diagnosis will be found
Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007 Feb;16(1):7-15. Review. PubMed PMID: 17297521; PubMed Central PMCID: PMC6634180.
Questions to distinguish the etiology of wheezing
Question Indication
How old was the patient when the wheezing Distinguishes congenital from noncongenital causes
started?
Did the wheezing start suddenly? Foreign body aspiration
Is there a pattern to the wheezing? Episodic: asthma
Is the wheezing associated with a cough? GERD, sleep apnea, asthma, allergies
Is the wheezing associated with feeding? GERD
Is the wheezing associated with multiple respiratory Cystic fibrosis, immunodeficiency
illnesses?
Is there a family history of wheezing? Infections, allergic triad

Weiss LN. Am Fam Physician. 2008 Apr 15;77(8):1109-1114.

Clinical evaluation and red flags
Most children will have no physical signs; however, none
will be found unless they are actively sought
Points to seek on examination suggesting underlying serious diagnosis

1. Bush A. Diagnosis of asthma in children under five. Prim Care Respir J. 2007 Feb;16(1):7-15. Review. PubMed PMID: 17297521; PubMed Central PMCID: PMC6634180.
Certain tests may also be required to evaluate lung
function of the child

FUNCTION TESTING
The pattern of the flow volume loops provides information about

PULMONARY
fixed or dynamic airway obstruction.
Child may require a few practice sessions to get reliable and
reproducible results
A normal spirometry result does not necessarily rule out asthma,
PEAK FLOW especially if patient has an intermittent asthma phenotype

Routine use of peak flow meters is not recommended

METERS

Measurement of peak flow can be helpful in patients who have poor

perception of their asthma symptoms and severity

Link HW. Pediatric Asthma in a Nutshell. Pediatrics in Review 2014, 35(7), 287–298. doi:10.1542/pir.35-7-287 
Differential diagnosis of wheezing according to
characteristic signs and symptoms
SIGNS AND SYMPTOMS PRESUMPTIVE DIAGNOSIS SUGGESTED EVALUATION
Associated with feeding, cough, Gastroesophageal reflux disease 24-hour pH monitoring Barium
and vomiting swallow
Auscultatory crackles, fever Pneumonia Chest radiography
Episodic pattern, cough; patient Asthma Allergy testing, Pulmonary
responds to bronchodilators function testing
Heart murmurs or cardiomegaly, Cardiac disease Angiography, Chest radiography,
cyanosis without respiratory Echocardiography
distress
Seasonal pattern, nasal flaring, Bronchiolitis (RSV), croup, Chest radiography
intercostal retractions allergies
Stridor with drooling Epiglottitis Neck radiography

Weiss LN. Am Fam Physician. 2008 Apr 15;77(8):1109-1114.

Differential diagnoses
Common, uncommon and rare causes of wheezing
in infants
Common Uncommon Rare
Allergies Bronchopulmonary dysplasia Bronchiolitis obliterans
Asthma or reactive airway disease Foreign body aspiration Congenital vascular abnormalities
Gastroesophageal reflux disease Cystic fibrosis
Infections- bronchiolitis, Immunodeficiency diseases
bronchitis, pneumonia, URTI
Tracheobronchial anomalies

Weiss LN. Am Fam Physician. 2008 Apr 15;77(8):1109-1114.

Differentiating the causes of wheezing in infants
Condition Estimated Clinical signs Investigations Clinical course
incidence
Viral wheezing Very common in Wheeze associated No specific 60% will outgrow
first 2 years of life with respiratory investigations wheeze by 6 years
tract infections
May be recurrent
Asthma 15–20 % of the Wheeze on a Spirometry with Usually expected to
paediatric regular basis; bronchodilator be lifelong but
population persistent/interval response (in clinical courses can
symptoms children older than vary
between episodes 5 years)
of viral wheeze

Souëf PL. The wheezing child: an algorithm. [Internet] [Accessed 2020 November 17] Available at: https://www.racgp.org.au/afp/2015/june/the-wheezing-child-an-algorithm/
Differentiating the causes of wheezing in infants
Condition Estimated Clinical signs Investigations Clinical course
incidence
Airways malacia Very rare Usually present soon after Bronchoscopy Majority outgrow it
the neonatal period with usually diagnostic by age 2 years
wheeze, stridor, cough and
rattling; children are usually
well and often labelled as
‘happy wheezers’
Protracted Exact Chronic wet cough Radiological Majority resolve
bacterial bronchitis incidence findings usually with 1–2 courses of
unknown normal  antibiotics

Souëf PL. The wheezing child: an algorithm. [Internet] [Accessed 2020 November 17] Available at: https://www.racgp.org.au/afp/2015/june/the-wheezing-child-an-algorithm/
Summary
The infant or child presenting to the physician’s office with persistent or recurrent
wheezing during the first two year’s of life poses a diagnostic dilemma

A focused examination and targeted diagnostic testing guided by clinical suspicion

provide useful information

Determining the cause of wheeze in young children can be difficult and

sometimes is determined only following a trial of treatment

Asthma is very common but other causes are also common and worth considering
POLLING
QUESTIO
NS
How often do you encounter wheezing in infants? What is the prevalence in your practice?
• <10%

• 10-30%

• 30-50%

• >50%
The prevalence of wheezing is more common in which age group under 3years?
• 0-6 months

• 6-12 months

• 1-2 years

• 2-3 years
Is are any gender dominance in prevalence of wheezing under 5years?
• Yes

• No

If yes, then
◦ Male

◦ Female
Have you observed different phenotypes in practice?

If yes, which ones are common?

◦ Infrequent

◦ Transient early wheezing

◦ Intermediate wheezing

◦ Late onset

◦ Persistent
Do you encounter babies with food/milk allergies associated with wheezing in your clinical
practice?
◦ If Yes, What is the prevalence?

◦ < 5%

◦ 5-10%

◦ 10-15%

◦ 15-20%

◦ Any others?
Which is the most common differential diagnosis of persistent wheezing in infants you
consider in practice?
◦ Asthma

◦ Infections

◦ GERD

◦ Cystic fibrosis

◦ Any other?
 Your Management
Strategies……please
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Wheeezing due to Asthma-IPD Wheeezing due to Asthma-OPD Wheeezing due to Food-milk Allergies