Consider parental perceptions when managing children with recurrent wheeze

Nasal symptoms are frequently reported as the first symptom of impending wheeze, but most parents believe strong cough is the most important indicator.

Issue: May 2007

SAN DIEGO — Children who are most likely to wheeze during a respiratory illness often have a strong cough at the beginning of their illness, according to recent trial results.

“We need to be open-minded in how to approach this situation. [Parental] perceptions then should be considered when formulating a management strategy for early intervention during respiratory tract infections among children with recurrent wheeze, and that these parental perceptions can be effective,” said Leonard B. Bacharier, MD, an associate professor of pediatrics at Washington University School of Medicine, St. Louis.

Bacharier discussed the Acute Intervention Management Strategies (AIMS) trial at the 2007 American Academy of Allergy, Asthma and Immunology Annual Meeting.

Parental perceptions

Bacharier and colleagues examined data collected from the AIMS trial to determine whether there are categories of early symptoms that predict wheezing during a respiratory illness and which specific early symptoms predict wheeze.

The researchers included 238 children aged 12 to 59 months with recurrent wheezing in the double blind, randomized, placebo-controlled AIMS trial. Parents completed questionnaires at the initial study visit and during all respiratory illnesses during the 12 months of the trial.

The average age of the children was 36 months; 65% were boys, and 44% were minorities, according to Bacharier. Of the parents, 67% were older than 30; a majority had some college education or beyond, and 80% had average household incomes greater than $30,000 per year.

The researchers asked the parents to choose which specific symptom first led them to believe their child was beginning to get sick and which symptom was the most important in informing them that their child’s illness will lead to significant wheezing.

The most commonly selected symptoms included nasal symptoms; “cough A,” which researchers defined as “infrequent and mild;” “cough B,” which they defined as “constant and concerning” and considered the typical “asthma cough;” noisy chest; breathing problems and behavioral problems, Bacharier said. Other symptoms, which parents infrequently chose, included fever and an ill-looking appearance.

The researchers found that the parents’ responses from first symptom to most important symptom changed. Although 41% of parents chose nasal symptoms as the first symptom of a respiratory illness, half of the parents considered cough B the most important symptom, and only 14% chose nasal symptoms as the most important.

“Nasal symptoms are frequently reported as an early sign of respiratory tract illness, but although they were recognized as very first symptoms, parents did not perceive these as reliable indicators of wheezing … coughing and a noisy chest are frequently reported early symptoms and are the most reliable antecedents for wheezing during illness,” Bacharier said.

Managing illness

Bacharier said that sensitivities of these measures in predicting wheeze are generally low. The highest sensitivity is that of cough B, and the lowest sensitivity is that of a noisy chest. Specificities are substantially higher, ranging from 45% when cough B is identified as the most important symptom to 100% when noisy chest is identified as the first symptom.

“It should be noted, however, that high specificity of noisy chest probably is related to the fact that wheezing is indeed one of the subcategories of noisy chest,” Bacharier said.

One hundred forty-eight of the children experienced at least two respiratory illnesses during the study period, and 39% of the parents provided the same responses for the first and second illness, according to Bacharier.

He also said that although coughing and noisy chest are the most reliable indicators of wheezing during illness, many children have different patterns of symptom development.

“These patterns appear to be individual-specific, and one size does not fit all,” Bacharier said. – by Lauren Riley

For more information:

Bacharier LB. Children ages 1-4: parental evaluation of clinical predictors of wheezing in young children. Presented at: The 2007 American Academy of Asthma, Allergy and Immunology Annual Meeting; Feb. 23-27, 2007; San Diego.