Recurrent bronchospasm in children under two years of age

Specialty: Pediatrics.

• Wheezing infant
• recurrent wheezing in the infant
• infant asthma

Why it occurs

• Bronchial hyperreactivity post-bronchiolitis (sequela of infection by Respiratory Syncytial Virus, Rhinovirus or Human Metapneumovirus that alters ciliary architecture and local immune response)
• Early onset childhood asthma (associated with atopic phenotypes, family history of asthma, eczema or allergic sensitization to pneumoallergens)
• Bronchopulmonary dysplasia (complication of prematurity and prolonged ventilatory support/oxygen therapy in the neonatal period)
• Pathological gastroesophageal reflux with recurrent pulmonary microaspirations
• Structural anomalies of the airway (tracheobronchomalacia, vascular ring or congenital bronchial stenosis)
• Cystic fibrosis or primary ciliary dyskinesia (genetic alterations in mucociliary clearance and composition of secretions)

Initial workup

Continuous pulse oximetry to evaluate gas exchange. Chest x-ray in anteroposterior and lateral projections (indicated in the first episode to rule out anatomical anomalies, suspicion of associated pneumonia, lobar atelectasis or suspicion of an aspirated foreign body with unilateral air trapping). Sweat test (to rule out cystic fibrosis if weight loss or digestive symptoms are associated). 24-hour esophageal pH-metry or impedanciometry if gastroesophageal reflux is suspected. Basic immunological study or skin allergy test (Prick test) or specific IgE if atopic phenotype is suspected after 12 months.

Standard management

• Salbutamol — short-acting beta-2 agonist; administration via spacer inhalation chamber with a face mask at doses of 2 to 10 insufflations of 100 mcg every 20 minutes in the first hour of crisis, or nebulized at doses of 0.03 to 0.05 ml/kg of 0.5% solution diluted in physiological saline
• IPratropium bromide — inhaled anticholinergic, synergistic with salbutamol in moderate-severe crises; dose of 250 mcg nebulized or 2 insufflations of 18 mcg every 20 minutes during the first hour
• Prednisolone or Methylprednisolone — systemic corticosteroids to reduce bronchial inflammation; dose of 1 to 2 mg/kg/day orally or intravenously for 3 to 5 days
• Montelukast (leukotriene receptor antagonist indicated as maintenance/control therapy in recurrent viral-induced wheezing; dose of 4 mg daily in granules or chewable tablets before bed).