Wheezing in children

Last updated: September 13, 2024

Summary

This article provides an overview of conditions causing wheezing in children. While acute wheezing in children may suggest a common cold, an acute asthma exacerbation, viral bronchiolitis, foreign body aspiration, anaphylaxis, acute bronchitis, or croup, recurrent or chronic wheezing may indicate a diagnosis of asthma, double aortic arch, primary ciliary dyskinesia, cystic fibrosis, tracheomalacia, or left-sided heart failure with cardiomegaly.

For more information on each specific condition, see the respective articles.

Acute wheezing in children

Differential diagnosis of acute wheezing in children
Disease	Age	Characteristics	Diagnostics
Common cold	Children < 6 years of age have an average of 6–8 common colds per year. ^[1]	Rhinorrhea, sneezing, nasal obstruction Sore throat, hoarseness Coughing Mild fever Malaise and fatigue	Clinical diagnosis Lungs usually clear to auscultation
Acute asthma exacerbation	Incidence of allergic asthma is highest in early childhood. ^[2] Median age of onset: 7 years ^[3]	Expiratory wheezing Tachypnea Accessory muscle usage Pulsus paradoxus Hyperresonance Silent chest Risk factors: history of atopy, allergic rhinitis, and/or eczema	Clinical diagnosis Spirometry is not feasible during most asthma exacerbations. Peak flow meter: PEFR lower than baseline
Viral bronchiolitis	Primarily affects children < 2 years of age during winter ^[4]	Prodrome with rhinorrhea, low-grade fever, dry cough Followed by wheezing, fine end-inspiratory crackles, tachypnea, nasal flaring, and intercostal retractions	Clinical diagnosis Chest x-ray: hyperinflation of the lungs, interstitial infiltrates, focal atelectasis Rapid antigen testing of nasopharyngeal secretions for RSV and influenza
Foreign body aspiration (FBA)	Primarily occurs in children < 3 years of age ^[5]	Sudden onset of dry cough, generalized wheezing, and choking Stridor Dyspnea Tachypnea Crepitus localized to the affected lobe May appear with cyanosis	Upper airway FBA: neck x-ray (radiopaque foreign object), laryngoscopy Lower airway FBA: chest x-ray (focal hyperlucency, reduced pulmonary markings, atelectasis), rigid bronchoscopy CT chest without contrast: in inconclusive chest x-ray; to guide planned removal of FB
Anaphylaxis	Occurs at any age	Dry cough Stridor, wheezing Dyspnea Chest tightness Urticaria, pruritus, angioedema Hypotension Most common trigger in infants: food	Clinical diagnosis Serology: elevated serum mast-cell tryptase
Acute bronchitis	Most common in children < 5 years of age ^[6]	Prodrome with rhinorrhea, sore throat, headache, malaise, myalgia Cough with or without sputum and chest pain Rhonchi, wheezing, fine crackles (rare) Mild dyspnea Fever (rare)	Clinical diagnosis CBC: mild leukocytosis Chest x-ray: normal or nonspecific (e.g., peribronchial thickening)
Croup (laryngotracheobronchitis)	Peak incidence: 6 months to 3 years of age ^[7]	Prodrome with rhinitis and low-grade fever Laryngotracheal inflammation phase: Seal-like barking cough Inspiratory stridor Dyspnea Pulsus paradoxus	Clinical diagnosis X-ray of chest and neck: subglottic narrowing (steeple sign) PCR: to identify viral pathogen

Chronic or recurrent wheezing in children

Differential diagnosis of chronic or recurrent wheezing in children
Disease	Age	Characteristics	Diagnostic findings
Asthma	Incidence of allergic asthma is highest in early childhood. ^[2] Median age of onset: 7 years ^[3]	Persistent, dry cough that worsens at night, with exercise, and/or on exposure to triggers and irritants (e.g., cold air, allergens, smoke) Wheezing Dyspnea Risk factors: history of atopy, allergic rhinitis, eczema	Pulmonary function tests showing an obstructive pattern: ↓ FEV1; ↓ FEV1/FVC ratio Bronchodilator administration showing reversibility of airflow obstruction Exercise or methacholine challenge testing: ↑ airway resistance and ↓ FEV1 indicate airway hyperresponsiveness CBC: eosinophilia Chest x-ray: normal in most patients, although hyperinflation of the lungs may be seen in some
Double aortic arch	Congenital; manifests in first weeks of life ^[8]	Tracheal compression: Inspiratory and expiratory stridor, dyspnea Apnea with cyanosis in severe compression Esophageal constriction: Dysphagia, choking, retching, vomiting Failure to thrive	Chest x-ray: anterior tracheal bowing and narrowing Echocardiography: to identify anomaly and associated congenital heart defects (e.g., VSD, tetralogy of Fallot, PDA)
Primary ciliary dyskinesia	Median age at diagnosis: 5.3 years ^[9]	Productive cough (due to recurrent respiratory tract infections and/or bronchiectasis) Wheezing and crackles Nail clubbing Failure to thrive Recurrent rhinosinusitis Chronic otitis media and conductive hearing loss Situs inversus	Chest x-ray: bronchiectasis, dextrocardia, situs inversus Nasal nitric oxide test: reduced levels Ciliary biopsy Genetic testing for PCD
Cystic fibrosis	Most are diagnosed at newborn screening or at 4–14.5 months ^[10]	Respiratory Chronic productive cough (due to recurrent pneumonia, chronic bronchitis, and/or bronchiectasis) Wheezing, dyspnea (due to pulmonary obstruction and airway hyperreactivity) Chronic sinusitis, nasal polyps Nail clubbing Barrel chest Gastrointestinal Meconium ileus Steatorrhea, diabetes mellitus, malabsorption (due to pancreatic insufficiency) Failure to thrive	Sweat chloride testing with a chloride value ≥ 60 mmol/L on ≥ 2 occasions CFTR genetic testing positive for mutations in the CFTR gene Chest x-ray: hyperinflation, reticular nodular pattern, bronchiectasis
Tracheomalacia	Congenital; symptoms usually manifest at 4–8 weeks of age ^[11]	Ineffective croup-like cough (due to tracheal collapse) Inspiratory and expiratory stridor, wheezing that may vary with activity and position Recurrent respiratory illnesses	Flexible bronchoscopy or dynamic CT: collapse of the trachea with deep breathing
Left-sided heart failure with cardiomegaly	Neonates and infants < 2 months of age with structural heart disease	Paroxysmal nocturnal dyspnea Exertional dyspnea, orthopnea (due to pulmonary venous congestion) Pulmonary edema Wheezing, bilateral basal rales Fatigue Nocturia Tachycardia, arrhythmia Cardiac auscultation: S₃ or S₄ gallop Pulsus alternans Cachexia Coolness and pallor of lower extremities	Chest x-ray: boot-shaped heart on PA view, increased pulmonary vascular markings ECG: left ventricular hypertrophy Increased natriuretic peptides (BNP or NT-proBNP) Elevated cardiac troponin T

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