The Canadian Pediatric Consensus Guidelines suggest that in young preschool children, a differential diagnosis needs to be considered especially if there is a poor response to asthma therapy. Go to Recommendations";
var hxDif2 = "
The differential diagnosis of wheezing from the Guidelines Go to Differential in the guidelines.";
//variables for family history
var hxFam = "There is a strong family history of allergy and asthma with both parents being allergic and mother having asthma.";
var hxFam1 = "
The Canadian Guideline recommendations on the diagnosis of preschool asthma stresses the importance of the family history in the diagnosis. Go to Recommendations.";
var hxFam2 = " The importance is based on the algorithm for distinguishing preschool non-atopic wheeze from atopic asthma published by Castro-Rodriguez et al.(2000).";
var hxFam3 = "
Family history of asthma and allergy is considered a major risk for expressing atopic asthma. Go to Algorithm.";
//variables for allergy history
var hxAll = "There is no history to suggest that the child is allergic, with no history of:";
var hxAll1 = "
";
var hxAll2 = " She constantly has rhinorrhea from frequent viral illnesses in daycare but no history to suggest that the rhinorrhea is allergic in nature.";
var hxAll3 = "
The Canadian Pediatric Consensus Guidelines stresses the importance of history in this age group since there is a significant difference in the outcome of allergic and non-allergic asthma. Go to Guidelines.";
//variables for environmental history
var hxEnv = "
An Environmental history should always be obtained when a child has recurrent wheezing including\:";
var hxEnv1 = "
APPROACH TO PEDIATRIC ASTHMA ACCORDING TO THE CANADIAN CONSENSUS GUIDELINES (BLACK TEXT).
"; var diag="DIAGNOSIS:"
+"
Most of the differential diagnosis suggested by the Canadian Pediatric Consensus Guidelines"
+" can by ruled out by the negative history. Go to Differential "
+" A chest x-ray should be done to help rule out other diagnoses in view of the degree she has been coughing. This would be especially true if there were findings on"
+" auscultation of the chest. Because she clears completely between colds, has no history to suggest a co-morbid condition and"
+" because auscultation was unremarkable, it is unlikely that there is anything"
+" sinister in the chest and the chest xray did prove to be normal. The Canadian Consensus Guidelines provides a symptom guide to facilitate the diagnosis of"
+" preschool asthma. Go to Guidelines "
+" If this child remains non-atopic as she ages, she has a good chance of outgrowing the wheezing problem."
+" Martinez 1995."
+" Martinez 1998."
+" The recent Canadian Pediatric Guidelines on the Management of Asthma has stressed the importance of the"
+" patient history and family history in distinguishing preschool viral-induced wheeze that is likely to be outgrown"
+" from atopic wheeze that is likely to persist. Go to Guidelines"
+" Allergy skin testing of preschool wheezing children as has been done in this case is useful since a negative result suggests viral induced asthma while a positive result"
+" raises the possibility of true atopic asthma with eosinophilic inflammation in the airways."
+" The Tucson algorithm for predicting atopic asthma in preschool wheezing children Castro-Rodriguez 2000"
+" has been recommended in the Canadian Pediatric Guidelines for predicting the outcome of wheezing in the preschool child."
+" Go to Algorithm"
+" The algorithm has recently been modified to include positive skin test to an aeroallergen as a major criterion and positive skin test to a food as a minor criterion."
+" Guilbert 2004"
+"
IN THIS CASE:
| WORKING DIAGNOSIS: Non-atopic preschool wheezing with a high risk for becoming Atopic Asthma"
+" KEY POINTS:
|
TREATMENT AT FIRST VISIT:
1. Environmental Control. This child is non-allergic and no-one smokes in the home."
+" Since the episodes of cough and wheeze occur with viral infections, there is very little that can be done"
+" to prevent them. Children in day-care develop frequent viral respiratory tract infections, virtually"
+" every three weeks in winter. Those children who develop cough and wheeze are usually just finishing one"
+" viral infection when they develop another, leading to snowballing of the symptoms."
//+" There must be no smoking in the home or car. Second hand cigarette smoke has been consistently associated"
//+" with severity and frequency of asthma symptoms especially if the person who is the primary caregiver smokes."
//+" Murray 1986"
//+" Cook 1999"
+" The Canadian Pediatric Guidelines continues to recommend the avoidance of"
+" environmental tobacco smoke in the secondary prevention strategies for asthma"
+" Go to Recommendations"
+" In the present case there is a strong family history of allergy, and I usually recommend allergy control should be done in the home."
+" However it is not clear from the literature that this will prevent the child from becoming allergic to the"
+" the specific allergens. Go to Recommendations"
+" Dust mite control should be done in the bedroom. The home should be checked for sources of mould. Unfortunately those measures will not help this child at the present time."
+"
2. Education The outcome of preschool wheezing should be discussed with the parents especially the" +" difference in outcome of nonatopic versus atopic wheezing i.e. preschool wheezing versus atopic asthma. The" +" risk suggested by the family history in light of the Tucson algorithm should be discussed. The spacer device" +" and puffer techniques should be taught along with the role of inhaled steroid.
"; var meds="3. Medication. The literature on the management of intermittent viral-induced wheezing in preschool children" +" is still controversial and that is because studies to date in this group of very young patients have been difficult to perform with" +" small numbers of subjects enrolled, with a lack of objective measures of asthma and a failure to separate the subjects" +" into non-atopic and atopic groups. Certainly if the asthma symptoms are chronic then the Canadian Pediatric Guidelines" +" recommend the same treatment as for older children i.e. maintenance with low dose inhaled corticosteroid" +" as first-line therapy. Go to Recommendations" +" The controversy surrounds treatment of preschool non-atopic children with intermittent viral induced symptoms and" +" the guidelines recommend against treatment with intermittent inhaled steroid." +" The controversy is well captured in the discussion of intermittent asthma in the Guideline document. Go to Discussion" +" Part of the problem can be traced to the fact that preschool children with atopic asthma or children with" +" criteria suggesting high risk for persisting, chronic, atopic asthma according to the Tucson algorithm cited," +" commonly present with intermittent viral-induced symptoms the same as non-atopic wheezers who are likely to outgrow the wheezing." +" These latter children who represent the majority of wheezing toddlers in the community. Reference Go to Guidelines are overtreated with maintenance inhaled steroid" +" and, in fact, may not respond to maintenance inhaled steroid. McKean 2000" +" In contrast the issue of management of atopic preschool asthmatics (which is likely to persist) is extremely important since there is evidence that" +" significant airway remodelling occurs in the preschool age in the atopic asthma group. Guilbert 2004" +" A study is underway to determine if these changes in lung function can be prevented by treating preschool" +" children at high risk for persisting asthma with maintenance inhaled steroid even when they have only intermittent symptoms." +" Guilbert 2005" +" There has been a recent large multicenter double-blind, placebo-controlled trial of Montelukast in the treatment" +" of preschool intermittent viral-induced wheezing (Previa study). The study was not reviewed in the recent Canadian Pediatric Consensus Guidelines" +" but it showed that the number of exacerbations could be reduced by a third compared to placebo. Reference" +"
IN THIS CASE:
| INITIAL MANAGEMENT: Fluticasone 50 mcg, 2 puffs bid."
+" KEY POINTS:
|
MANAGEMENT AT FOLLOW-UP:
With recent onset, non-atopic, preschool wheezing, it should"
+" be possible to achieve full control of symptoms, that is, no symptoms night or morning, no symptoms with exercise and no requirement for bronchodilator."
+"
The response to the treatment plan should be evaluated carefully and"
+" she should be monitored regularly over the next year. Initially she should return in 1 month."
+"
If full control has been achieved:"
+"
"
+"KEY POINTS:
|
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' +diag+'Your Treatment: '+document.getElementById('message1').value+'
Your Follow-up: '+document.getElementById('message2').value+'
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