INHALED CORTICOSTEROIDS FOR PERSISTENT WHEEZE IN PRESCHOOL CHILDREN

To the Editor :

The study by Nielsen and Bisgaard (1) demonstrates that it is possible to undertake reliable and discriminatory lung function tests in preschool children. International asthma guidelines advocate the use of inhaled corticosteroids (ICS) in preschool children with persistent wheeze. The authors observe that in young children the diagnosis of asthma on reported symptoms can be ambiguous, and use lung function measurements to measure the effect of ICS. Recruitment to the study was based on a presumptive diagnosis of asthma, defined as the presence of symptoms on 7 or more out of 14 d during the run-in period. Baseline lung function in these children was abnormal and improved on the dose of ICS chosen for the study, thus providing objective evidence for the reported improvement in symptoms.

In the United Kingdom guidelines are not always followed. It is difficult to find published data reporting the prevalence of preschool intermittent wheeze and preschool persistent wheeze. It is our experience that the majority of preschool wheeze is intermittent. In this group, continuous ICS do not prevent wheezy episodes presumed to be viral-induced (2). However, almost 60% of preschool boys with wheeze have been prescribed ICS (3). It is known that treatment adherence in this age group is poor (4). Now that lung function can be studied in preschool children, it should be possible to demonstrate whether lung function improves with ICS between episodes. Then, clear guidelines for the treatment of this large group of wheezy children can be based on objective measurements, as well as symptom reporting.

The Royal London Hospital, Royal London National Health Service Trust, London, United Kingdom

1. Nielsen KG, Bisgaard H. The effect of inhaled budesonide on symptoms, lung function, and cold air and methacholine responsiveness in 2- to 5-year-old asthmatic children. Am J Respir Crit Care Med 2000; 162: 1500-1506 [Abstract/Free Full Text].

2. Wilson N, Sloper K, Silverman M. Effect of continuous treatment with topical corticosteroid on episodic viral wheeze in preschool children. Arch Dis Child 1995; 72: 317-320 [Abstract].

3. Majeed A, Moser K. Prescribing for patients with asthma by general practitioners in England and Wales 1994-96. Health Statistics Quarterly 1999;16-20.

4. Gibson NA, Ferguson AE, Aitchison TC, Paton JY. Compliance with inhaled asthma medication in preschool children. Thorax 1995; 50: 1274-1279 [Abstract/Free Full Text].

From the Author :

We thank Drs. Pao and McKenzie for their supportive comments on our study of the effect of inhaled corticosteroids in young preschool children as documented by objective measurements of lung function and bronchial hyperreactivity (1).

The majority of studies on pharmacotherapy in older children and adults with asthma have been performed in moderate-to-severe asthma. Treatment of mild or intermittent asthma is therefore mainly by extrapolation. We agree that ICS, leukotriene receptor antagonists, and other possible treatment options should be studied also in young asthmatic children with mild or intermittent symptoms, and preferably by objective measurements as introduced in our recent studies (1).

Copenhagen University Hospital, Copenhagen, Denmark

1. Nielsen KG, Bisgaard H. The effect of inhaled budesonide on symptoms, lung function, and cold air and methacholine responsiveness in 2- to 5-year-old asthmatic children. Am J Respir Crit Care Med 2000; 162: 1500-1506 .

2. Bisgaard H, Nielsen KG. Bronchoprotection with a leukotriene receptor antagonist in asthmatic preschool children. Am J Respir Crit Care Med 2000; 162: 187-190 [Abstract/Free Full Text].

3. Nielsen KG, Bisgaard H. Lung function response to cold air challenge in asthmatic and healthy children of 2-5 years of age. Am J Respir Crit Care Med 2000; 161: 1805-1809 [Abstract/Free Full Text].