Anti‐inflammatory pharmacotherapy for wheezing in preschool children

Abstract

Accumulating evidence indicates that there are at least two phenotypes of wheezing in preschool years with distinct natural history. Frequent wheezing in the first 3 years of life with risk factors for asthma (e.g., eczema, maternal asthma) predicts symptoms in older age, while infrequent viral-associated wheezing without risk factors for asthma has a benign prognosis. This systematic review summarizes evidence on the use of anti-inflammatory medications in preschool children with wheezing. Literature search was performed using Medline and the Cochrane Library. Retrieved articles were critically appraised. Episodic use of high-dose inhaled corticosteroids (>1,600 mcg/day of beclomethasone) may ameliorate severity of intermittent viral-associated wheezing. Maintenance inhaled corticosteroids can control symptoms in children with frequent wheezing associated with risk factors for asthma. Inhaled corticosteroids do not alter the natural history of wheezing even when started early in life and could have a negative impact on linear growth rate. Short courses of oral corticosteroids have been proposed as an effective measure to control exacerbations of symptoms although there is little evidence supporting their use. Some studies support the administration of non-steroidal anti-inflammatory medications (leukotriene pathway modifiers, cromones, methylxanthines) for mild frequent wheezing. Maintenance inhaled corticosteroids is the most effective measure for controlling frequent wheezing in preschool children, especially when accompanied by risk factors for asthma. This treatment does not affect the natural history of wheezing, although deceleration of linear growth rate is the most commonly recognized systemic adverse effect.

Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach

“…The long-term consequences of inhaled steroid therapy on growth in preschool children have not been studied. Clinically relevant effects on adrenal function have only been observed in children receiving high doses of ICSs (.400 mg?day -1 beclometasone equivalent) [106]. The risk of cataract was not increased in a study of 358 children aged 1-3 yrs receiving daily treatment with ICSs for o1 yr [114].…”

“…Inhaled corticosteroids in treatment of symptoms of multipletrigger wheeze A systematic review of randomised double-blind controlled trials of inhaled glucocorticosteroids in preschool children with multiple-trigger wheeze has shown significant improvements in important health outcomes, including symptoms, exacerbation rates, lung function and airway hyperresponsiveness [106]. The treatment effect appears to be smaller than that seen in schoolage children and adults.…”

“…For example, studies of ICSs in preschool children with multiple-trigger wheeze have reported a reduction in exacerbations by ,50% [107,108]. Compared to placebo, children using 200 mg?day -1 fluticasone exhibit a mean of 5% fewer days with symptoms [106].…”

“…Systematic reviews have concluded that episodic high-dose inhaled glucocorticosteroids (1,600-3,200 mg?day -1 budesonide) provide some benefit in episodic (viral) wheeze (with a 50% reduction in the requirement for oral steroids, but no effect on hospitalisation rates or duration of symptoms), but that maintenance treatment with 400 mg?day -1 beclometasone equivalent does not reduce the number or the severity of wheezing episodes in episodic (viral) wheeze [106,115]. It should be emphasised that the available evidence is based on a few small trials that may be underpowered for the detection of a treatment effect.…”

“…The clinical benefits of ICSs for episodic (viral) wheeze are controversial [106]. Systematic reviews have concluded that episodic high-dose inhaled glucocorticosteroids (1,600-3,200 mg?day -1 budesonide) provide some benefit in episodic (viral) wheeze (with a 50% reduction in the requirement for oral steroids, but no effect on hospitalisation rates or duration of symptoms), but that maintenance treatment with 400 mg?day -1 beclometasone equivalent does not reduce the number or the severity of wheezing episodes in episodic (viral) wheeze [106,115].…”