Posted tagged ‘Asthma’

Recurrent wheezing in preschoolers

May 18, 2015

The Pediatric Insider

© 2015 Roy Benaroch, MD

Maura wrote: “I’d appreciate a post on treating and understanding intermittent asthma (viral induced) in preschoolers. I’m currently very confused about whether the risks and benefits of treating with inhaled steroids are well established.  I’m also confused about what the literature means when they say ‘exacerbation’ of asthma.  Thank you!”

Hoo boy. This is one of those questions that would get different answers to if you asked a room full of pediatricians. Different answers, and arguing, and maybe a thrown chair or two.

Heck, we’re not even sure if we should call this asthma. So I’ll back up to what we all can agree on, first.

A “wheeze” is a specific physical exam finding. It’s a whistly, almost musical sort of chest noise, the noise you hear when air tubes are constricted. Most (but not all) wheezing is heard during expiration. Children who are wheezing almost always cough, and cough is the main symptom of most wheezy illness. It makes sense—the airways are constricted, so the body tries to “pop” them open with a forceful expiration. Coughing can open airways and at least temporarily relieve the airway constriction and wheeze.

Lots of health conditions cause wheezing, and at least 25% of children will wheeze at least once. Mostly typically, it’s caused by a viral infection. Whatever you do or don’t do to treat it, the noise will go away and Junior will stop coughing. But recurrent episodes of wheezing, that’s when things get interesting. And controversial.

In older children, school age and up, the most common—by far—cause of recurrent wheezing is asthma.  These kids usually have multiple triggers for their wheezing, including allergies, infections, cold air, and exercise (not all kids will have all of these triggers). Albuterol is the mainstay medicine to quickly stop wheezing and coughing once it starts. Inhaled steroids are the best medicine to use to prevent wheezing flare-ups (called “exacerbations”—that’s when kids with asthma have symptoms like coughing, wheezing, chest pain, and shortness of breath.) Inhaled steroids as preventive medicines work and they’re safe. Kids with asthma who use daily inhaled steroids have far fewer exacerbations, miss less school, and stay healthier.

But there’s another group of children in whom the usefulness of inhaled are less clear-cut. These are toddlers and preschoolers, little kids, who have recurrent wheezing episodes only triggered by one thing: viral infections. They get a cold, they start to wheeze. These kids seem to respond less robustly to both inhaled albuterol (which, especially in the youngest children, may not work at all), and less well to inhaled steroids, too.

Some people don’t even think we should label these little ones with recurrent wheeze as having asthma, because that can mislead us into using treatments that are less effective. A suggested label is to say these children have “WARI”, or Wheeze Associated with Respiratory Infections. Some docs say these kids have “RAD” or reactive airways disease, or “recurrent bronchitis”, or “viral pneumonia”, or recurrent “bronchiolitis”.

What makes this especially difficult is that we can never tell, from the first or second wheeze episode, if a child is going to end up with asthma (recurrent wheeze of many triggers) versus WARI (recurrent wheeze only triggered by infections.) Some suggest we look at family history, or whether the child has eczema or food allergies, but that history doesn’t reliably predict the future course of wheezing. What we really need is some kind of test or biomarker to predict who will really benefit from inhaled steroids. We don’t have any great way to know.

Inhaled steroids are safe, at least in ordinary low doses. In higher doses some growth suppression can occur, though that may disappear with long-term use. And we know out-of-control asthma, with frequent wheezing, will also stunt growth.

As always, risks and benefits have to be weighed. If a young child has infrequent flare-ups easily treated with albuterol I’m less likely to suggest a trial of an inhaled steroid; but if flare-ups are frequent or severe or land a child in the emergency department, daily inhaled steroids are worth a try. There’s some art here, and a lot we don’t know, and plenty of room for discussion between doc and parent about what’s best for each childs’ circumstances. The chair throwing, that’s optional.

I feel a song coming on!

I feel a song coming on!

Lick the pacifier, prevent asthma?

June 17, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Those wacky, wacky Swedes. They’ve given us the Fyrkantig candle at Ikea. And the word “nomofob.” And now, a study of babies whose parents sucked pacifiers. Not their own, parental pacifiers—their babys’ pacifiers.

Researchers in Sweden published a study in the May, 2013 issue of Pediatrics. They  looked at a group of 184 babies, interviewing the parents about their pacifier cleaning techniques. At six months, there were 65 parents who were “suckers”—these are the ones who reported that they routinely cleaned their child’s pacifier in their own mouths. The rest of the families said that they used other kinds of cleaning techniques. Maybe they used a stranger’s mouth. Frankly, I don’t want to know.

Anyway: at 18 months and again 36 months of life, the babies were examined for findings of allergic disease. The researchers reported that at 18 months, “sucking” was associated with less asthma and less eczema; at 36 months, only eczema still seemed to show any difference in the two groups.

It’s an interesting study, but I don’t think it’s very conclusive. It’s interesting that the asthma “protection” seemed to disappear at three years (I wonder if the eczema “protection” waned later.) And the overall protective effects weren’t particularly large. In nerd-statistics language, the confidence intervals almost overlapped odds or hazard ratios of 1.

Also, studies like these don’t show that the intervention—parental pacifier sucking—was what caused less allergic disease. I imagine that these families who cleaned pacifiers in their mouths were otherwise somewhat less diligent about cleanliness. Perhaps that’s what accounts for the difference, not the pacifier habits themselves.

I also have some misgivings about suggesting that parents slurp away on their kids’ pacifiers. Many people carry bacteria in their mouths that contribute to tooth decay, and it would be unwise for those families to continually re-inoculate their babies. There are other mouth germs, too—strep, herpes, and who-knows-what-kind-of Swedish meatball germs (as featured in this documentary.)

I’m sure an occasional, in-a-hurry-and-just-want-it-clean-enough suck is harmless, but it really doesn’t make sense to go out of your way to put your child’s pacifier in your mouth. If you want one that badly, go buy your own.

Can acetaminophen cause asthma?

May 28, 2013

The Pediatric Insider

© 2013 Roy Benaroch, MD

Tylenol (acetaminophen) replaced aspirin as everyone’s favorite pain reliever-fever reducer in the 1980’s, when aspirin was linked to a rare fatal liver disorder called Reye’s Syndrome. Acetaminophen is very widely used now, even in newborns, and is considered safe as, well, something very safe. Except maybe it isn’t.

Some evidence is adding up that acetaminophen could be linked to the rising rates of asthma in the developed world. There’s a certain biologic plausibility to it—acetaminophen depletes the body of glutathione, which may prevent that molecule from stopping inflammation in the lungs. And several epidemiologic studies, and at least one randomized trial from 2002, have seemed to confirm the link. The positive evidence for the association was summed up in this New York Times article from 2011.

However, a more recent NYT article, this one from last week, refutes the claim. The article quotes the author of an as-yet-unpublished study who says that it’s not the medications like acetaminophen that increase asthma risk, but common upper respiratory infections—which are often treated with Tylenol. If this author is correct, the acetaminophen is going along for the ride, but isn’t itself causing the asthma.

That’s science for you. A whole lot of studies, and we’re still not sure.

What I am sure of is this: all medicines, if they’re biologically active at all, have side effects. There is just no way around that. If someone is trying to sell you a perfectly-safe “medicine”, it isn’t a medicine. It’s a placebo.

No medicine ought to be taken unless it’s needed, and when doctors and patients think about the risks and benefits of any medication, we ought to figure in at least a little fudge factor for possible risks we don’t even know about yet.

Related posts:

Tylenol versus Motrin

Acetaminophen safety alert (2009)