Wheezing toddlers: viral wheeze, asthma, inhalers and steroid fears

Many toddlers wheeze with colds, and most of them do not have lifelong asthma. An inhaler with a spacer works as well as a nebuliser, and inhaled steroids, used at the lowest dose that works, are far gentler than parents fear. The hard part is knowing which wheezy child needs which treatment, and that becomes clearer over time.

Why does my toddler wheeze every time they catch a cold?

Because a toddler's airways are very narrow, so a little swelling and mucus from a cold narrows them a lot. Wheezing with colds is common in young children.¹

A wheeze is a high, whistling sound, mostly heard when your child breathes out. It comes from air squeezing through tight, swollen airways.

In a well known study from Tucson in the United States, about a third of the children followed from birth had at least one wheezy chest illness before the age of three.¹ Children whose airways worked less well as babies, before any chest illness, were more likely to wheeze in this way and then stop.¹ In Kolkata, Dr Dutta sees the most wheezy toddlers in the monsoon and the cooler months, when colds go round homes and playschools.

Does wheezing mean my child has asthma?

Not always. Many toddlers who wheeze only with colds do not go on to have asthma.¹

In the Tucson study, more than half of the children who wheezed before age three had stopped wheezing by age six.¹ These children did not have a higher chance of allergy or asthma later.¹

A smaller group kept wheezing. They were more likely to have a mother with asthma and signs of allergy in their blood tests.¹ In these children, the early wheezing was probably the start of asthma.

So Dr Dutta is slow to label a two year old "asthmatic" after one or two wheezy colds. She is equally slow to call it "just a cold" if a child coughs and wheezes every week.

What is the difference between viral wheeze and asthma in toddlers?

Episodic viral wheeze happens only with colds, and the child is completely well in between. Multiple-trigger wheeze also happens at other times, and is more like asthma.²

A European expert task force uses these two simple patterns:²

• Episodic (viral) wheeze: wheezy only during a cold, fine between episodes.
• Multiple-trigger wheeze: wheezy during colds and also between them.

Between colds, the triggers Dr Dutta asks about are running, laughing, crying, dust, smoke and cold air, and a cough at night. In the Tucson study, asthma in the mother made ongoing wheeze more likely.¹ Eczema is another clue she looks for.

The same task force notes that children often move from one pattern to the other over time.² So the label is a working guide, not a final verdict. Dr Dutta reviews it at every visit.

How do doctors diagnose asthma in a child under five?

Mostly from the pattern of symptoms over months and how the child responds to treatment. There is no single test that settles it in a toddler.

Breathing tests (spirometry) need a child who can blow hard on command, which most children under five cannot do. The European task force says tests are only needed when the diagnosis is in doubt.²

What helps Dr Dutta most:

• A diary of wheezy episodes, with dates and what set them off
• A short phone video of your child breathing during an episode
• A note of whether the reliever inhaler clearly helped
• Family history of asthma, eczema or hay fever

This is not doctors being vague. It is simply how asthma shows itself in small children.

Could my child's wheeze be something other than asthma?

Yes, sometimes. A few wheezy children have a different problem that needs a different plan.

Dr Dutta looks harder when:

• The wheeze started suddenly after a coughing or choking fit while eating or playing. A peanut, a piece of toy or a seed may have gone into the airway.
• The baby has wheezed or had noisy breathing since the first weeks of life.
• The child is not gaining weight, has loose, oily stools, or has a cough that is wet every single day.
• The child vomits a lot with feeds, or has repeated pneumonia.

A sudden choking episode followed by cough or wheeze needs to be seen the same day, even if your child then seems fine. In babies under one, a first wheezy illness is usually bronchiolitis, which is a different illness and is treated differently.

Is a nebuliser better than an inhaler for my toddler?

No. An inhaler (the "pump") used with a spacer gives the medicine to the lungs at least as well as a nebuliser.³

A Cochrane review pooled 39 trials, including 1897 children from two years of age with acute asthma. Children given the medicine by spacer did no worse than those given it by nebuliser. They left the emergency room about half an hour sooner, had a slower heart rate and less shakiness.³

The European task force also recommends the inhaler with a spacer for wheezy preschool children.²

Many Indian families think nebulisers are "stronger" and inhalers are habit-forming. Neither is true. A spacer is quick, quiet, needs no electricity, and works in the car or at 3 in the morning. A nebuliser takes longer, frightens many toddlers, and a lot of the mist ends up on the face and in the room.

How do I use an inhaler with a spacer and mask for a toddler?

Fit the inhaler into the spacer, seal the mask over the nose and mouth, press once, and let your child breathe normally through it for several breaths.

Step by step:

1. Take off the cap and shake the inhaler.
2. Push it into the end of the spacer.
3. Hold the mask firmly over your child's nose and mouth, with no gaps.
4. Press the inhaler once.
5. Keep the mask in place while your child takes several slow, normal breaths.
6. For a second puff, shake again and repeat. Give one puff at a time.

A crying child breathes in less medicine, so practise when your child is well. Let them hold it, decorate it, or "give a puff" to a teddy first. Older children can use a mouthpiece instead of a mask. Ask your doctor or nurse to watch you do it once. Most problems with inhalers in Dr Dutta's clinic come from technique, not from the medicine.

Are steroid inhalers safe for young children?

Yes, at the doses we use, for the children who need them. An inhaled steroid sends a tiny dose straight to the airways, so very little reaches the rest of the body.

When parents hear "steroid", they think of the weight gain and weak bones seen with long courses of steroid tablets. Inhaled steroids are measured in micrograms, a tiny fraction of a tablet dose. In preschool children with persistent asthma, a daily inhaled steroid cut the number of serious attacks compared with a dummy inhaler.⁴

Rinsing the mouth or giving a drink of water after each dose lowers the small risk of oral thrush (a white fungal coating in the mouth). Wiping the face after using a mask also helps.

The side effect that does matter is a small effect on height, explained in the next answer.

Do inhaled steroids stunt a child's growth?

They can reduce adult height slightly, by about 1 cm on average. The effect happens early and does not keep adding up year after year.⁵

The best data come from a US trial that followed children with asthma into adulthood. Children aged 5 to 13 who took a daily inhaled steroid for 4 to 6 years ended up 1.2 cm shorter, on average, than those given a dummy inhaler.⁵ Higher doses in the first two years were linked with a bigger effect.⁵

That is why Dr Dutta aims for the lowest dose that keeps your child well, and review it often. For a child who would otherwise be wheezing every few weeks, missing playschool and getting steroid syrups, most families feel the trade is worth it. It is a decision she makes together with the family.

Does my wheezy toddler need a daily preventer inhaler?

Only some do. A daily inhaled steroid helps most in toddlers who wheeze often, or who have symptoms between colds.^2,4

The European task force recommends daily inhaled steroids for multiple-trigger wheeze, while noting the benefit is often small.² A review of 15 trials found daily steroid inhalers reduced attacks needing steroid tablets or syrup in preschool children with recurrent wheeze.⁴

For a child who wheezes only with the occasional cold and is well in between, Dr Dutta usually gives a reliever inhaler (salbutamol) during each episode and nothing in between.

If a preventer is tried, Dr Dutta treats it as a trial and reviews it after a couple of months. If there is no clear benefit, she stops it, as the task force also advises.²

Should a steroid inhaler be started at the start of every cold?

This approach can reduce bad attacks in children with cold-triggered wheeze, but it uses high doses and is a decision for your paediatrician.^4,6

In a review, children with viral-triggered wheeze who started a high-dose steroid inhaler at the first sign of a cold had fewer attacks needing steroid syrup or tablets.⁴

One of the main trials behind this used a high dose twice a day for up to 10 days with each cold. It cut the use of rescue steroid medicine by about half, but children on it grew a little less in height and weight. The authors advised against using this widely until the long-term effects were clearer.⁶

So Dr Dutta does not hand this out routinely. She keeps it for selected children with frequent, severe cold-triggered attacks, with close follow-up of growth.

Do steroid syrups help a toddler with viral wheeze?

Often not. In a large trial of toddlers with mild to moderate viral wheeze, a 5-day course of prednisolone did not shorten their hospital stay.⁷

The trial included 700 children aged 10 months to 5 years in England. Prednisolone was no better than a dummy medicine for any of the outcomes measured.⁷

In Dr Dutta's practice, steroid syrup still has a place in more severe attacks, and in older children with clear asthma. Your doctor may give a short course of a few days. That is very different from long-term steroid tablets. What she would like families to avoid is a steroid syrup with every cold "just in case".

Is montelukast safe for children?

Montelukast can help some wheezy toddlers, but it can affect mood and sleep. Stop it and call your doctor if you notice changes in behaviour.^2,8

The European task force suggested montelukast as one option for episodic viral wheeze.² That advice was written in 2008, before the FDA warning below. In 2020, the US Food and Drug Administration added a boxed warning about mental health side effects.⁸ These include:⁸

• Bad or vivid dreams and trouble sleeping
• Agitation, aggression or irritability
• Anxiety, depression or restlessness
• Sleepwalking
• Suicidal thoughts and actions

If your child is on montelukast, watch for these. The FDA advises stopping it and talking to a doctor straight away if they appear.⁸

Why does my child cough at night but seem fine in the day?

A night cough that keeps coming back, even without a cold, can be a sign of asthma. It can also come from a runny nose dripping down the back of the throat.

Most coughs in children follow colds and settle over a few weeks, even when the child sounds dreadful. These do not need an inhaler or an antibiotic. Honey in warm water can ease a cough in a child over one year old. Never give honey to a baby under one.

Things that point towards asthma:

• A dry cough most nights, for weeks, between colds
• Cough or wheeze with running, laughing or crying
• A cough that clearly settles with a reliever inhaler
• Eczema, or asthma in a parent

Cough syrups are not useful for asthma cough, and many are not meant for young children. A cough that goes on for weeks without settling needs a proper check.

Does smoke at home make my child's wheezing worse?

Yes. Children exposed to tobacco smoke are more likely to start wheezing and to develop asthma.⁹

A review of 79 studies found that smoke from parents or others in the home raised the risk of new wheezing in children by 30 to 70 percent.⁹ The strongest link was a mother smoking after birth, for wheeze in children up to two years old.⁹ The European task force also advises keeping wheezy children away from tobacco smoke.²

In Indian homes Dr Dutta also asks about mosquito coils, agarbatti, dhuno, a coal or wood stove, and smoke from burning rubbish nearby. These are common and often forgotten. A smoke-free home is one of the few things in wheeze that is fully in your hands. Smoking on the balcony still brings smoke in on clothes and hands.

When should I take my wheezing child to hospital?

Go to the emergency department straight away if your child:

• Is working hard to breathe: the skin sucks in between or below the ribs, the nostrils flare, or the tummy pumps in and out
• Is too breathless to talk, feed or play
• Needs the reliever inhaler more often than your written plan allows, or it is not helping
• Has blue or grey lips or face
• Is unusually quiet, drowsy or exhausted (a wheezy child who goes quiet may be getting worse)
• Started wheezing suddenly after choking on food or a small object

Book a routine visit if your child wheezes often, coughs most nights, or needs steroid syrup several times a year. A clear written plan, a spacer used well and a smoke-free home do most of the work.