Guideline updates management of recurrent wheezing in infants

A newly developed consensus guideline from the Committee of Pediatrics of the China Medical Education Association outlines a structured approach to the diagnosis, treatment, and long-term management of recurrent wheezing in infants and toddlers.¹

Published in 2025, the recommendations address a common but heterogeneous clinical presentation that remains challenging because of limited diagnostic tools and overlapping etiologies in children younger than 3 years. The panel used a modified Delphi process and systematic literature review to generate 31 recommendations spanning evaluation, pharmacologic treatment, and prevention. The document emphasizes the importance of distinguishing wheezing phenotypes and identifying underlying causes to guide management and improve outcomes in early childhood.

“The lack of standard guidelines for managing recurrent wheezing in infants and toddlers has resulted in inconsistent implementation of therapeutic and preventive strategies.... The guidelines developed by us can provide a framework for improving the management of recurrent wheezing in infants and toddlers worldwide,” said Yunxiao Shang, PhD, professor at the Shengjing Hospital of China Medical University.²

Diagnostic approach emphasizes etiology and clinical context

The guideline defines recurrent wheezing in infants and toddlers as at least 3 episodes separated by symptom-free intervals of 7 days or more.¹ This contrasts with the Global Initiative for Asthma definition, which considers at least 2 episodes within 12 months in children younger than 5 years.

Investigators highlight that recurrent wheezing has multifactorial causes, including virus-induced wheezing, early childhood asthma, and protracted bacterial bronchitis, as well as less common conditions such as airway malformations or gastroesophageal reflux. A detailed clinical history and physical examination are emphasized as central to diagnosis, particularly given the nonspecific nature of symptoms in this population.

Key elements of history include age at onset, triggers such as viral infections or allergen exposure, response to medications, and family history of atopy. Physical examination should differentiate expiratory wheeze from inspiratory stridor and assess for signs of hypoxia or systemic disease.

The guideline recommends several ancillary tests to support diagnosis. Blood eosinophil count and allergen testing are strongly recommended to identify type 2 inflammation and asthma risk.

Chest radiography is advised routinely, with computed tomography reserved for unclear cases or poor treatment response. Fractional exhaled nitric oxide testing may help identify eosinophilic airway inflammation, although its use remains limited in very young children. Pulmonary function testing is suggested but should be interpreted cautiously because of age-related limitations.

Treatment strategies vary by severity and suspected phenotype

Management is stratified by acute exacerbations and remission periods. For acute wheezing episodes, inhaled corticosteroids are recommended for severe exacerbations or suspected asthma, whereas short-acting β-agonists remain first-line bronchodilator therapy. Evidence cited by the panel indicates that inhaled corticosteroids reduce symptom severity and need for systemic steroids in high-risk children, but do not prevent asthma development.

Systemic corticosteroids are not recommended for mild episodes and show limited benefit overall, although they may be considered in severe cases suggestive of asthma. Routine antibiotic use is discouraged, given that viral infections are the most common trigger, although antimicrobial therapy is appropriate when bacterial etiologies such as protracted bacterial bronchitis are suspected.

During remission, low-dose inhaled corticosteroid maintenance therapy may be considered for children with frequent or severe episodes or those diagnosed with asthma. The guideline notes that daily inhaled corticosteroids are more effective than leukotriene receptor antagonists for symptom control and exacerbation reduction. Leukotriene receptor antagonists may be used selectively, although clinicians are advised to discuss potential neuropsychiatric adverse effects with caregivers.

Beyond pharmacologic treatment, the guideline underscores the importance of addressing modifiable risk factors. Environmental control measures, including reducing allergen exposure and avoiding tobacco smoke, are strongly recommended. Regular assessment of nutritional status and comorbid type 2 inflammatory conditions, such as atopic dermatitis or allergic rhinitis, is also advised.

The authors recommend establishing a longitudinal follow-up plan with periodic reassessment, given that wheezing phenotypes may evolve over time and early symptoms can influence long-term pulmonary function.

“Despite the complex and diverse etiology, lack of symptom specificity, and diagnostic challenges of recurrent wheezing in infants and toddlers, the cause can be identified through detailed history taking, physical examination, necessary ancillary tests, and regular follow-up assessments,” wrote investigators.

References

1. Committee of Pediatrics, China Medical Education Association, Cooperative Group of Asthma, et al. Evidence-based guideline for clinical practice in the diagnosis, treatment, management, and prevention of recurrent wheezing in infants and toddlers in China. Pediatr Investig. 2026;00:1-20. doi:10.1002/ped4.70046
2. Pediatric investigation study develops guidelines for managing recurrent wheezing in children. News release. Pediatric Investigation. March 26, 2026. Accessed April 3, 2026. https://www.eurekalert.org/news-releases/1121491