Wheezing in infants and toddlers — what to do?

June 22, 2009  |  General

Wheezing is common in small children — around a third of all children will have an episode of wheezing before they are three years old. Although it’s common, we still don’t quite know the best thing to do about it. The problem is that wheezing, like fever, is a symptom of a disease, not a disease itself. It’s not one thing. Every physician who treats small children in the office, the emergency department, or the pediatric intensive care unit is often faced by the dilemma of what to do with a wheezing small child.

In such children wheezing is often triggered by a viral illness. When it happens in infants it is often caused by a virus we call RSV (short for respiratory syncytial virus) and causes a disorder called bronchiolitis. For those children, we know that not much of anything helps the symptoms — all we can do is provide supportive care and wait for the illness to run its course. What about wheezing children who don’t have bronchiolitis? Can anything help them?

The problem facing the doctor is that all the treatments we’ve tried over the years for small children who wheeze are taken from how we handle older children who have chronic, frequent wheezing — what we call asthma. These treatments work for asthma, yet they often don’t for wheezing that isn’t. A certain number of children who have their first spell of wheezing will go on, over years, to develop true asthma. But most wheezing toddlers won’t progress to asthma — they will have an episode or two (or three) of wheezing and then “grow out of it.” If you bring your infant or toddler to the doctor for a first (or second) episode of wheezing, the doctor has no way of knowing which of these two things will happen. There are a few clues, such as a family history of asthma, which will increase the chances of future asthma, but there’s no good way to tell.

How do most doctors handle this problem? Most will try a dose or two of asthma medications (inhaled albuterol and/or budesonide, or oral prednisolone are commonly used) just to see if it helps. If the child gets better, they can be continued.

My point is that you should understand that for this problem — wheezing in an infant or toddler — your doctor is handicapped by not being able to predict the future. Only time will tell. It’s a frustrating, but common medical scenario.

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44 Comments


  1. Thank you very much for this very informative post. As a mom of a 13 month old who had two wheezing episodes (both coincided with viral fevers/cold) in less than a month which required over night hospital stay for observation…I arrived at your post looking for answers. Your post gave me a lot of clarity and much needed assurance that we are doing everything we could for our little one. Thank you!

  2. I’m glad you found it helpful

  3. My 15mo son has always been a “loud breather.” At first, the docs and nurses said it was because he was a section baby and didn’t get that final squeeze.

    With each visit to the pediatrician, the first thing out of my mouth is “he’s still a loud breather.” I’ve had several docs listen to him, and they all say the noise isn’t in his lungs.

    Then at 10mo we had an attack of croup. I hoped the steroids would cure the problem.

    No such luck. Now that it’s turned cold outside, my son seems to be breathing even louder. It’s similar to the croupy sound, but not the same.

    Do I become that crazy mom? Or do I see if he grows out of it?

  4. Hi Natasha:

    I can’t give you specific advice, of course, but it sounds to me as if your son just has an airway smaller than average. Another possibility is that he has what we call a “floppy” airway (it has a fancy name — laryngal or-tracheomalacia). Kids with that tend to be noisy breathers. The problem generally does solve itself when the child grows bigger. The experts on this sort of thing are either pediatric allergists or pediatric pulmonologists (lung specialists). If you are really concerned about it I’d suggest finding one of those two specialists.

  5. Hi Dr. Johnson

    I found your blog very interesting, I am a student of medicine at the Catholic University of Maule in Chile, and I’m very interested in the area of pediatrics. As you said there are many blogs that talk about caring for children, but only his focus on an important topic as critical care of children. I also really like his vision of treating children as a whole and not piecemeal, as was done earlier with general medicine. I commend him for his work and I hope your next post.

    Carefully
    Constanza Bustos.

  6. Dr.Johnson, thank you for your article! My son has wheezing this winter with almost every cold. The doctor has prescribed Flovent and it helps. My concern is that we have to use this medication for very long periods of time. What could be the possible side effects?

  7. Hi Anna:

    Inhaled steroids like Flovent have been extensively studied in children and, although no medicine is totally without risk, they are extremely safe, even for prolonged periods of time. In your son’s situation, doctors often recommend using them through the winter cold season. If he is doing well in the spring, you could discuss with your doctor stopping them to see how he does

  8. Dear Dr.Johnson, thank you very much for your reply! My son is doing well for a month and a half now. The doctor said we should use Flovent 125 mg once a day till the end of February. We are supposed to see our doctor in March. I would like to ask you what would be the right way to wean my son off this dose of Flovent? Should we switch to a smaller dose or just stop it (we are using it once a day)?

  9. At that dose, and for inhaled steroids like Flovent, usually we just stop the medication. But I’d do as your doctor suggests because I can’t really give specific medical advice over the Internet.

  10. My 15 month old has been battling with wheezing, coughing, congestion and ear infections. We have been doing breathing treatments of albuteral and budesonide for 7 months along with antibiotics and steroids; in the last 3 months, he has been on antibiotics 4 times. He seems to get a little better when he’s on antibiotics, but never completely better- he still wheezes when he is really active. The doctor recommended ear tubes, but my concern is that tubes will not solve our problem. What do you recommend for chronic wheezing/coughing? If that and the congestion are under control, would we even need the tubes?

  11. Hi Katie:

    I can’t give you specific medical advice over the internet without seeing your child in person. However, I can say that you’re correct that ear tubes generally aren’t used to treat wheezing problems — they’re for ear problems, most commonly recurrent ear infections.

  12. my son is 2 years old – he has had 2 episodes of wheezing due to cough – doctor had first given him 2 ml per time /4 times a day to inhale ventalin through a nebuliser – he was very uncomfortable and we found that doctor has wrongly given him an overdose – so we consulted another doctor and they said yes surely its overdose as right dose shld be 0.25 ml – and doctor advisd us better to use the ventalin puff with a spacer and take 2 times a day as its only mild wheezing – we are worried about our son that by taking 4 days of overdose of inhaled ventalin -4 times each day – could it cause any major side effect to him – after his first episode of wheezing -after one week he had another episode due to viral cough – plz advice if it will cause any harm to him of taking overdose – also kindly let us know will he grow out of wheezing and what we should do to make his lungs stronger – in our family we dont have any history of asthama – plz help doctor – we are our worried about our 2 year old son

  13. Generally speaking, albuterol is a very safe drug. We sometimes use it very high doses in severe asthmatic cases (much higher than your son received), so we have some experience with high levels of it. There are no aftereffects once the drug is stopped, so I wouldn’t worry at all about that for your son.

    Regarding the wheezing your son had with a virus infection, that is very common. Although there is no way to be sure, most children grow out of that as they get older. The fact that there is no history of asthma in your family is no guarantee he will not have asthma later, but it does make it less likely.

  14. I was wondering about not only the effects of the medicine but what it means for my son as a thriving three year old. He had RSV when he was six months old and it was a struggle to get the doctors to confirm it.We have been taking breathing treatments off and on for almost his whole life. Now he had what they think was Bronchitis but he was had severe wheezing since October and it is January. The doctor has given him 4 rounds of anitbiotics and 3 rounds of steroids. It has gotten to the point that I feel horrible about giving him his breathing treatments and I am worried that he will have to have them for even longer. Is there anything that could be recommended that might be a different approach for us to take?

  15. Hi Alicia:

    It’s not appropriate for me to give specific medical advice over the internet (I hope you’ll understand), but I can say that the sort of thing your son is experiencing as not that rare. It’s common for children who have had RSV to have wheezing problems long after the RSV is gone, and to have a higher risk of developing asthma. Sometimes this continuing wheezing problem can be pretty severe. One thing I could suggest is that you might consider taking your child to see a pediatric pulmonologist — a lung expert — if you haven’t already. They’re expert in handling things like that.

    The good news is that problems such as your son has tend to get better as they grow older. So statistics are on your side.

    Good luck.

  16. hi mr.christopher

    my son 3 n half years old.now he s having wheezing for 3rd time.. everytime when i consult vth dr he put d neobilizer n den he will b fine.. i want to cure his wheezing completely ..sometimes at night he s having cough severely until vomit..

    one of my fried suggested me to give him rhinathiol promethazine..i juz wanna ask u is it ok to give him ds medicine as its contains 3.09% of alcohol i’m bit worried of it.. n one more thing is i have another child who is 15month old . does ds wheezing will spread easily from my son to daughter?

  17. Thanks for stopping by. I’m sorry that I can’t give you specific medical advice over the internet — it isn’t appropriate for me to do that. But your questions are good ones, and your child’s doctor is the best person to answer the specifics.

    As a general principle, though, wheezing in toddlers gets better as they get older most of the time. So usually treating the symptoms with such things as nebulized albuterol does the job. But again, your child’s doctor is the best person to ask the specific questions.

  18. thank u so much for ur quick reply..

  19. Dear Dr Johnson,
    My son is 6 months old and has been coughing over 2 weeks with 2 days of wheezing. Otherwise no fever, tolerating feeding well and active. He has been given regular nebulized ventolin. I would like to ask if there is a role for oral prednisolone?His elder sister is asthmatic and usually given oral prednisolone during acute attacks.

  20. Diana:

    I can’t give you specific medical advice over the internet, but I can say that prednisolone (or another oral steroid) is often used in that setting, typically as a 5 day course. An inhaled steroid, such as fluticasone or budesonide, is then often used afterwards. Your child’s doctor would be the appropriate person to decide if a plan like this is the best thing to do for your son.

  21. Dear Dr. Johnson,

    Found the above article very pertinent to what we are going through right now. Many thanks for all the patient replies, I am hoping for this to continue.

    Our 1yr old daughter started to suffer with what seemed like a routine cold/flu 7 weeks ago. We just saw it as that, assuming she would shake it off. One thing has led to another, and she was battling a pretty nasty wheeze last night, ended up getting hospitalised for a second time during these 7 weeks. While the XRAY showed a chest infection around two weeks ago, the actual cause hasn’t been fully confirmed yet. She is on her second course of antibiotics, in case it is bacterial, part of which was IV administered (augmentin?). The doctors here (Singapore) have said exactly what you’ve said – they can’t know if this is her first case of asthma, or it is the result of a viral infection.

    Shouldnt they be able to confirm if it is viral or not? It would be good to know.

    What could be done to get her airways cleared? She is being given ventolin inhalers, being kept on oxygen when her saturation levels drops to low 90s (as far below to 84 at one point today), also through IV, some fluids glucose with dextron(?), also something through IV to reduce inflammation and to open up her airways (i don’t recall what they are called). She doesn’t seem to be responding and this has been going on for weeks. Im not sure what they will try tomorrow.

    But any kind of knowledge or guidance you could share I would like to suggest just as a matter of available alternatives. She is really suffering (mostly during nights), any thoughts would be appreciated.

    Mark

  22. Hi Mark:

    Of course I can’t practice medicine over the internet, but it sounds to me as if your child’s doctors are doing what I would be doing — oxygen as needed, IV fluids if not drinking well, albuterol, and steroids (which I assume the anti-inflammatory medicines you mentioned are). Usually we give antibiotics as well because we can’t be sure the infection isn’t from bacteria. It can be quite frustrating, both to parents and to the doctors (we get frustrated, too). The problem is that as things are happening we really don’t know if this sort of thing is the beginning of a chronic problem (such as asthma) or is just the result of a particularly nasty infection. I can offer a few things to keep in mind, though.

    Regarding diagnosing viral infections, our ability to do this is not very good. One reason is that viruses are very difficult to grow in the laboratory, unlike bacteria. We do have some rapid screen tests looking for particular viruses (respiratory syncytial virus — aka RSV — and influenza, for example) but those tests just answer a yes/no question; they don’t tell us what is there if the screen answer is no. The other problem is that the lung is hard to get at to sample potential infections, both viral and bacterial. Urine and blood, for example, can just be sampled and put in the microbiology laboratory to see what grows. We can’t do that with the lung easily (or safely) — mucous coughed up is not necessarily representative of what is down in the lung.

    Another thing to remember is that wheezing episodes from lung viral infection really can go on for several months. Typically the severe part — needing oxygen and hospitalization — clears in a few days or so, maybe as long as a week — but the wheezing can go on for quite some time. I have had patients with wheezing from viral lung infections get very, very ill and spend weeks in intensive care. You should take comfort in the fact that nearly all the time if the child is going to get that ill it happens early in the illness, which hasn’t happened with your daughter.

    Also, when a child recovers from a viral infection that made them wheeze they tend to do it again if they get another respiratory virus within the next several months — it takes that long for the lungs to heal completely. But the more times that happens the more likely the problem will turn out to be something chronic, like asthma.

    The bottom line is that many, many children — the majority, really — experience what your daughter is going through and end up just fine with no chronic lung problems.

    Good luck and I hope you found this helpful.

  23. Very helpful from a grandparent viewpoint. I was babysitting our 1yo grandson last winter when he had a wheezing episode. Scared me, I called his parents who took him to their family doctor who told them EXACTLY what you have written. Only reading here helped me understand it better. The wheezing, by the way, lasted only for that illness and has never happened again.

  24. I’m glad you found it helpful — and that your grandson did well.

  25. Eugenia Garcia-Oliver

    Dear Dr Christopher!

    I am very impressed with all your replies and would like to therefore consult you on my child.

    Exactly one month ago he had a cough that developed into wheezing.As new parents we did not recognise the gravity of it all, and only after a terrible night in which he threw up three times and was really unwell did we take him to A and E. They tried oral medication (Saubetamil, prednisone, etc) but nothing woukd work.He finished up in the High Dependancy Unit with Iv medication.

    One month later, sneezing begun followed by a cough.We were scared and when I noticed last Friday wheezing we returned to A and E. He was given ten puffs of the inhaler, prednisone and a weaning programme.I don’t think he is still wheezing and what is scary now is his erratic behaviour.He is screaming, sleepless, angry and moody. he is taking Singulair for the last five days that was prescribed by the allergy specialist last week (before he knew we had a new case of wheezing).

    In your knowledge, can Singulair be causing these side effects?How can we prevent in future more episodes?We were told to give him Singulair for teo weeks only but I have since then found out that it should be taken for a long period of time.Is that right?

    Lastly, my Dr back home has insited on us getting a steroid inhaler, but Dr here are not proposing that.My son does need some care, he is allergic to five foods: eggs, peanuts, treet nuts, sesame, chickoeas.

    Any help greatly appreciated since saying we are confused frustrated and lost would be an understatement,
    .

    Best,
    Eugenia

  26. Thanks for your interest. For legal and ethical reasons I can’t give you specific medical advice about your child over the internet because I’m not his physician. From your description, however, it sounds as if his problems are not unusual for a child who has wheezing. It can indeed be very frustrating.

    Although I can’t give you specific advice, I have not encountered montelukast (Singulair) as causing the problems you describe. However, it is well known that oral steroids can cause symptoms similar to the ones you describe. But they are also very effective in controlling wheezing in the short term, so sometimes we just have to put up with the other effects of the drug. If steroids are needed for a longer period we usually use inhaled steroids, such as budesonide.

    Again, I understand your frustration. But the odds are that he will get better as he gets older no matter what the doctors do.

  27. hi, i have been having problems with my son since he wad around 2 yesrs old where every now and again he would wake up always through the night with a bad wheeze streaming nose and barking cough. Each time i have called the doctor and filled the bathroom up with steam which does help. Each epidode lasts for approx 60 mins st a time. This has slways been diahnosed as croupe but he has also had a referal to an asthma nurse who said it was to early to diagnose. He is mow 4 and dtill has these “attacks” but there can be months in between them and he always appears to have made a full recovery after. Still scary for me and him and im scared one time he doesnt wake up or i dont hear him. I have had no luck from his dictor wjo sees mothing wrong? Any thoughts or ideas? Thanks

  28. Hi Kelly:

    Thanks for stopping by, but I can’t really practice medicine over the internet so I can’t give specific advice without seeing your child. I guess the bottom line to me is that if he is having these spells less frequently and they are less severe, then that is encouraging.

  29. About one year ago my 4 year old grandson began having a nagging dry cough and allergy symptoms (frequent sneezing, congestion, rhinitis). Our pediatrician thought he may have a reactive airway and started him on Xopenex via nebulizer and a Pulmicort inhaler with absolutely no improvement in symptoms over several months. He does not wheeze, but coughs and is short of breath at all times. A recent URI brought on a trip to the ER where his croup-like cough was treated with inhaled epinephrine and a 5 day course of prednisone or prednisolone. From there we consulted a pulmonologist who prescribed albuterol, Flovent, a PPI for possible reflux, and a future bronchoscopy if he doesn’t improve. After several weeks on this regimen of meds, we see no improvement in his symptoms. He coughs from the moment he awakens, all day long, is worse at night, and sounds short of breath when he speaks. I have never heard of a child having cough (without wheezing) as a variant of asthma; his symptoms never abate or lessen, he doesn’t have days or weeks where he doesn’t cough or sound short of breath; it’s constant. We have a pulse oximeter and he’s always around 98 or better, so we’re struggling to understand what is going on with him. No family history of asthma, eczema, allergies, etc. He hasn’t seen an ENT or allergist but I think that should be the next step. How common is it for asthma to manifest as a cough and shortness of breath without wheezing? And any thoughts on why he would fail to respond to the beta2 agonist and/or inhaled steroids? Thank you – K.

  30. Hi Karen:

    I can’t give detailed and specific medical advice on an individual case over the internet because I’m not there and I’m not your child’s doctor. However, I can offer a few comments. There are a few children whose only manifestation of asthma is cough — they never wheeze. But, as you point out, the anti-wheezing medicines should have made things better if that were the cause, and they have not. So I would doubt that as the principal cause, although it may be contributing.

    At this point I think I would return to the pulmonologist to see if it is time to do bronchoscopy to see just what is down there in the airway that could be causing the cough. There are various possibilities that the pulmonologist could discuss with you.

    Good luck to you and your child

  31. My daughter is having wheezing problem for the past one month and our Paediatrician has recommended to use Albuterol Sulfate Inhalation solution (2.5MG/3ML) with a Nebulizer for six days. She was ok during those 6 six, but developed the same problem after we stopped using the Nebulizer.

    She also has food allergy to Wheat, White Egg and Milk.

    Is it ok to continue the Albuterol with Nebulizer, whenever she is having trouble. Can we also give her Allegra when she is giving Nebulizer treatment.

    Your advise please.

  32. Thanks for stopping by, but I can’t give specific medical advice over the internet because I’m not your child’s’ doctor. I can say, though, that albuterol is an extremely safe drug.

  33. Wow this website is awesome! You are great! My son is 4 months old and for two months now he has been wheezing with course rattles in chest that you can hear arms feel. Tried nebs and 5 days of steroids. He does not improve. Next step is meds for acid reflex. My questions are, is it normal for a baby to be this sick for this long? I am so worried about this. And can acid reflex really cause this sigbificant of respiratory issues? He has had crackles in his lungs and x rays to rule out pnuemonia. I feel they have no clue and are playing a guessing game. Why won’t they just try antibiotics?

  34. Hi Rainel:

    I can’t give specific medical advice over the internet because I’m not your child’s doctor. I can say that acid reflux disease can indeed cause significant respiratory problems in a 4-month-old. Good luck and thanks for stopping by.

  35. Hello Dr,

    Our son’s ped diagnosed him with wheezing today (and it could be related to a cough or RSV infection). We are doing the albuterol treatment via nebulizer every 4-6 hours. My concern is: I plan to fly to India from the US in the second week of January with my son (~ 2wks from now)….and if the wheezing continues until then, is it safe for him to travel? We will take two flights – one 16 hours long (non-stop) and another 3.5 hour flight with a short layover in between. What can be taken in-flight with us to help him? Thank you!

  36. I can’t give specific medical advice over the internet because I don’t know your child — only his doctor can give you specific advice regarding the safety of your trip. I can be a few general comments, though, that you might find helpful. The so-called cabin altitude of a commercial airplane is about 7,000 feet above sea level. That means if a person is receiving oxygen therapy at sea level, he most likely will need additional oxygen when he is up in the plane. If your son doesn’t need extra oxygen now then this is not a problem.

    Regarding breathing treatments, there are alternatives to the nebulizer for giving albuterol that you could take on the plane — ask you doctor about it. We typically use the nebulizer on small children because it is easy, but there are other options.

  37. Hello! I would like to say how informative your site is and we thank you for that. My 4 year old doesn’t usually have health issues but all of a sudden for the second time in a couple of months, without any other symptoms will have a sudden coughing fit and then I’ll notice slight wheezing. I didn’t take her to the Pediatrician the second time because the first time he said he heard nothing, that she must have had some sort of obstruction that she got out. I would like to add that I have a recent history of Pulmonary Embolism. I don’t think that would be her issue, and I know you can’t give individual med advice for obvious reasons, but my question is is slight wheezing a medical emergency? Should I run to the ER or Pediatrician whenever it happens? Her Dr. kind if dismissed it the last time so I’m confused as to how serious this can be. Thank you for your service!!

  38. As you say, I can’t give you specific advice since I’m not your child’s doctor. However, it is reasonable to say that wheezing in itself does not require a trip to the doctor. What is important is how bad it is. If the child is not really in any distress, then there is no need to go. If the wheezing persists or is quite frequent, though, that is worth a visit to the doctor to see if the child needs a course of anti-wheezing medicine or other tests.

    I hope this helps you and thanks for stopping by.

  39. I have a six month old premie who had had several episodes of wheezing over the past few months. He has had a confirmed case of influenza and para influenza as well as an ear infection. This last bout of wheezing has lasted almost 3 weeks now following his infection. He is currently on a puffer and oral steroids which don’t seem to be helping. He was also born at 34 weeks and is a twin.

    My question is: is it common for episodes of wheezing to last this long and does it cause discomfort to baby?

  40. Hi Natalie:

    Yes, wheezing after viral infections, especially in former premature infants, can persist for months. This is particularly the case if the viral infection was from influenza or RSV. After these, the airways of a small child often respond to subsequent viral infections, even from common cold viruses, with wheezing. These things do tend to get better as the child grows bigger, but it would not be unusual for him to have troubles for the rest of the winter and early spring at least.

  41. Hello,
    I have come across this sight and was wondering if you can offer advice. My son is almost 8months and has wheezed and been breathless everyday since he was 5months. It comes on suddenly and can have chest retractions if its a bad episode. Ventolin doesnt help, he has been on atrovent which does help to manage it at home and stops the symptoms for 6hours or till the next day if hes having a good day. He has recently been given inhaled steroids to try for 2months (he has been on them 2weeks now) but he still wheezes and the breathlessness is worse. He was admitted to hospital at 8&12 weeks with what they think was rsv and was tube fed and on oxygen and nebuliser. Chest xray was clear and he tested negative for rsv. I was also told it didnt follow the usual pattern of rsv as he had no cold symptoms and he was better within 3days also it was july so was out of season. They havent diagnosed him with anything but treating as though asthma. I feel like they are missing something, do his symptoms sound like anything else that they could be overlooking. He was born on time, has no weight or growth issues. I hope you can help, many thanks, melissa.

  42. Hi Melissa:

    I can’t give specific medical advice over the internet because I am not your child’s doctor. It wouldn’t be ethical. However, I can say in general terms that persistent wheezing of the sort you describe in your son is not uncommon. We usually treat these children as your son is being treated, with asthma medicines, even though we don’t use the word asthma in a child so young because we don’t know how things will be in a year or so. The bottom line is that persistent wheezing with viral illness of the sort your son has is not uncommon. And, as you have found, it is frustrating. The good news is that the majority of children get better as they get older. You might consider consulting a lung expert, called a pulmonologist, if you have not already done so. They are expert at the use of all those anti-wheezing medicines.

  43. My daughter is 6 month old and wheezing, with a small dry cough. She has no fever and is still very happy. Could it be caused by teething? If not do you have any ideas? And what can i do??

  44. Hi:

    I can’t give specific medical advice over the internet because I am not your child’s doctor. It would not be ethical. However, I can tell you that teething does not cause wheezing. If she looks well I wouldn’t worry about it myself.

Trackbacks

  1. Wheezing in infants and toddlers: we still don’t know what’s best to do | Christopher Johnson M.D. PICU Author
  2. Just what is wheezing, anyway? | Christopher Johnson M.D. PICU Author