Resolved question:
My 5 months infant had an acute Bronchiolitis attack last week. He was hospitalized for 4 days for treatment with nebulizers consisting of a mixture (0.2 ml Ventolin, 0.8 ml Pulmicort and 3.0 ml normal Saline) at a frequency of once every 4 hours. On the third day, they gave him 2.5 ml prednisolone twice a day orally then they increased it to 3.0 ml doses.
Upon discharge, we were provided with the following medicines to continue administering:
1. Prednisolone: to complete the 5 days course.
2. Butalin inhaler: to be administered with a chamber (3 sprays every 8 hours for 7 days course).
3. Budiair inhaler 200 mcg. (1 spray every 12 hrs. for 1 week to be reduced to 1 spray for the following 30 days.
4. Singulair Paediatric 4mg Granules (1 sachet per day for two months course)
5. Propolis Nasal Spray for two months use.
Two days after coming back home, my son’s health seemed to have improved in some aspects and digressed in others.
His chesty coughs and noises felt better while his throat condition seemed worse as he sort of lost his voice and his nose is still runny so we took him to another pediatrician.
The new doctor added an Antibiotic (Augmentin 62.5 mg/ ml to be administered three times per day)
I would like a second opinion on the treatment plan
I am most concerned about the suitability of the medicine for an infant specially the second one as it does not indicate so when I read the literature.
Submitted:
4 Days
Category:
Pediatrician
Hello,
Thank you for your query at DoctorSpring.com
I can understand your child's situation. Bronchiolitis is one of the most difficult pediatric emergencies because of various reasons:
1. There is no definitive cure - as it is secondary to a viral infection
2. Most of the available therapeutic options are not of proven benefit.
However, because of the disease's self-limited nature, infants rarely develop complications.
In your child's case, there are a few things that I need to clarify before we discuss the treatment provided:
1. Is this the first episode ? Has the child had any respiratory symptoms till date?
2. Is there a history of atopic dermatitis, allergic rhinitis (recurrent sneezing/ allergy to dust) or asthma in any of the parents or other relatives?
3. Does the child have any skin rash or drying or dermatitis/eczema?
4. What is the country and city of your residence? What is the climate in your region at this point?
Regards,
Dr. Saptharishi L G
Thank you Dr. Saptharishi for your reply. Answering your queries, please read below: 1. Yes this is his 1st episode. 2. Yes there is a history of atopic eczema as well as allergies and bronchial asthma in the family. 3. I am not sure if my child has developed any skin rash yet. However we noticed that during his hospitalization he got into scratchibg his eyes and nose. At home, only his nose. But that could be due to his runny or blocked nostrils. 4. we live in Jeddah, Saudi Arabia. It is located by the Red Sea. It is mostly humid climate. However we have dusty winds every now and then. I hope that gives you a better insight to the problem. Awaiting your reply. Best regards. Mohammed Alaidarous
Dear Parent,
Thank you for providing me with all the above information. Now the situation is much clearer. Let us analyse your child's treatment in light of this:
Your child's condition would be ideally labelled as a 'Multi-trigger WHEEZER' rather than bronchiolitis. In children who have a familial tendency of atopy or allergy or asthma, there is a tendency of the body to over-react to triggers and produce bronchospasm and produce wheezing. A viral infection can be such a trigger.
In a child without any predisposing background, the viral infection produces 'bronchiolitis' that is self-limiting in nature. It does not produce such severe symptoms, and even if it does, does not show much response to bronchodilators, or other nebulized drugs. There may be very minimal response to adrenaline nebulisation. But, steroids (for 5 days) is never used in bronchiolitis. It is part of management of Asthmatic exacerbation.
In your child, there is a STRONG TENDENCY for his airways to overreact for any trigger (These genes run in your family based on your history). In this case, though the viral infection could have triggered the wheezing, your child's description is not that of a 'classical bronchiolitis'. Your child is at risk for ASTHMA when he grows up but right now, though he is behaving like and has been treated as asthma, he CANNOT be LABELLED as ASTHMATIC. That label is only given to children > 3 years old patientage.
My diagnostic label for your son would be - 'MULTI-TRIGGER WHEEZER'
Moving to the management, your child has received appropriate initial therapy considering the severity of his attack. However, there are a few concerns:
1. the use of MONTELUKAST (Singulair) in such a young child is contra-indicated and in fact, there is a FDA ban on its use in children younger than 6 months. Ideally, it is to be used only in children older than 6 YEARS.
2. The PROPOLIS nasal spray is based on Gangalin, a compound derived from honey/ honey bees. Its effectiveness as a nasal spray is questionable and there is no strong evidence to support its use in young infants. That is a questionable choice.
3. Management in lines of a multi-trigger wheezer means that apart from prednisolone that was used in your son, we have to use BUDI_AIR and BUTALIN sprays for at least 3 months regularly. That management would be in line with the international recommendations on management of multi-trigger wheezers with a strong tendency for bronchospasm.
Regarding your child's voice problem, it is most likely to be due to the use of steroid (Budecort- Budi-air) inhaler. After its use, you are supposed to be instructed to feed the baby or wash the mouth immediately in older children. If that is not done, the drug gets deposited in the the throat and leads to infection- pharyngitis/ laryngitis and may cause voice problems. I think you should start feeding the child immediately after a dose of inhaled steroids to prevent its deposition in the throat.
I do not think there is any indication for the antibiotics, that your child has been prescribed. Episodes of runny nose and difficulty breathing (bronchospasm) are going to be common in your child. Treatment with antibiotics every time would be utterly UNWISE.
Hope this was helpful,
Regards.
Dear Dr. Saptharishi:
Thank you for your prompt reply.
Noticing that my son have improved significuntly today and based on your analysis, I am thinking about discontinuing SINGULAIR. Also, I am planning to limit this antibiotic course to 5 days instead of the prescribed 7 days.
Please advise whether you would concur with this or not.
Best regards
Mohammed Alaidarous
Dear Mohammed Alaidarous,
I am glad that you have understood my point of view. My suggestions would be:
1. Stop SINGULAIR and PROPOLIS nasal spray
2. Continue inhaler BUDECORT (Budi-air) twice daily for at least 3 months - 400 micrograms/day - Low dose inhaled corticosteroids
3. Use BUDESONIDE (butalin) whenever your child has any wheezing
4. STOP antibiotics unless your child is running high-grade fever
5. Start the practice of feeding after administration of inhaled steroid
Regards.
Dear Dr. Saptharishi: With regards to Budiair, I think three months of steroids is a cause of concern. Please advise probable side effects that we should watch for. As for the antibiotics, do you recommend immediate stoppage?. Isn't there a minimum course duration we should abide by? I, also forgot to ask an important question: The Doctor recommended running allergy test (specific IgE for wheat, milk, egg and house dust mite). he indicated that is a must to treat his "asthma". Please share with me your thoughts about the required allergy testing. I am concerned about this because it is a series of expensive tests that are not covered by my Company's Medical Insurance Policy. I need a supporting argument to justify this. Best regards
Dear Parent,
The standard treatment for acute exacerbation of asthma/ multi-trigger wheezer is three month regimen of inhaled steroid. Please do not worry about side effects as low dose inhaled corticosteroids DO NOT have any of the side effects of systemic oral steroids. Millions of children are on inhaled steroids worldwide for asthma and do not have any short term/ long term complications. There are multiple clinical research studies on this topic. Please feel free to cross-check. Secondly, the dose that we are going to use is 400 mice/day viz. a small dose only. Systemic absorption of this dose in your child would be minimal.
No, you need not abide by any minimum duration. I feel that you can stop it right away as there seems to be no evidence of any bacterial infection in your child.
I would not deem those tests may be necessary for diagnosis or management of asthma. Clinical observation for allergy is more useful. If needed, a skin prick test can be done. IgE for wheat, milk and egg may not be necessary now. Those are indicated when one suspects FOOD ALLERGY to these food products.
Hope this was helpful,
Regards.