Pediatric Wheezing: If Not Asthma, Then What is It?

When a child experiences coughing, wheezing and chest pains while engaged in physical activity, the default conclusion is that the child must be suffering from exercise-induced asthma (EIA). However, there are several other explanations for wheezing in pediatric patients often overlooked and therefore, left untreated. A featured science session at the 55th Annual Meeting of the American College of Sports Medicine (ACSM) addressed the issue of pediatric wheezing and the possible diagnoses beyond EIA.

Lucien R. Ouellette, M.D., session chair, explained that there is plenty of confusing information about EIA, how to approach it and how to treat it. Ouellette and co-presenter Michael Pleacher, M.D., outlined alternative diagnoses to explain pediatric wheezing that may present while engaged in physical activity, the appropriate tests and proper treatments.

"Unfortunately, it's all too common for athletes to be diagnosed with exercise-induced asthma, only to miss the real source of the wheezing," said Dr. Ouellette. "These patients are frequently treated with an inhaler only to continue experiencing the symptoms. The patient then quits using the medicine since it's ineffective, and the true diagnosis is left undetected."

Asthma is certainly a problem for children and receives a considerable amount of attention because of environmental causes such as second-hand smoke and air pollution. According to the American Lung Association, asthma is the most common chronic disorder in children, currently affecting an estimated 6.8 million children under 18 years old, of which 4.1 million suffered from an asthma attack or episode in 2006 according to data from the U.S. Centers for Disease Control and Prevention (CDC).

Because of the increasing prevalence of asthma, it's easy to explain why EIA is a common diagnosis for children who wheeze (expiratory noise) or have stridor (inspiratory noise). However, many non-asthmatics may present asthmatic symptoms triggered by exercise (exercise-induced bronchospasm).

In a recent study, researchers from the University of Iowa examined 142 pediatric patients referred for exercise-induced dypsnea, 98 of whom had been presumed to have EIA by their primary care physician. Upon further examination, only 11 patients (9 percent) actually had EIA. Seventy-four (63 percent) patients were exercising too hard or were not properly conditioned for their activity level. Other diagnoses included restrictive abnormalities (13 percent), and vocal cord dysfunction (11 percent), among others.

Ouellette and Pleacher detailed eight common non-asthmatic conditions during the session. The conditions (listed in alphabetical order) are:

1. Deconditioning -- when the patient is not in shape for the engage physical activity

2. Exercise-Induced Anaphylaxis -- allergic reaction to exercise

3. Foreign Body Aspiration -- inhaled items

4. Gastroesophageal reflux disease (GERD) -- a digestive disorder of the lower esophageal sphincter

5. Hyperventilation -- excessive breathing

6. Psychogenic Cough -- a dry, non-productive cough associated with emotional or psychological problems

7. Tracheomalacia -- collapse of the airway

8. Vocal Cord Dysfunction -- closing of vocal cords when breathing in

Ouellette explains that replicating the situation and symptoms is important for an accurate diagnosis. "For example, if a patient is a swimmer, you should test them at the pool. If they are a hockey player, you should test them in an ice-rink where the environmental elements are consistent."

While a pulmonologist, allergist or ear, nose and throat specialist are perfectly qualified to treat these patients, these professionals may miss an important explanation for the symptoms based on athletic performance. A sports medicine specialist is trained to consider how physical activity may be causing the problem and perform some of the testing that may best uncover the solution.