January 27, 2020

 I am taking a one week pause on the cardiology story to refine the next tricky section.

 Winter is here and we are seeing an increased volume of children with viral related wheezing disorders. Bronchiolitis, a term that means inflammation of the bronchioles, is a viral associated illness that causes significant lung inflammation in children under the age of three years old. It is one of the leading causes of hospitalization in this age group.

This illness is usually benign and self limited as the cough and wheezing fade away over a few days to a week without intervention. However, it can also be scary as some children will present with cough, fever, wheezing and further respiratory compromise over time. Some high risk individuals need to be aware of this disease, including: premature or low birth weight newborns, children with immune system defects, cardiac disease, chronic lung disease and/or severe neurological disease.

Respiratory syncytial virus (RSV), rhinovirus, parainfluenza, influenza, adenovirus and metapneumovirus are the major pathogens that cause this disease. RSV is the most common and serious player in this group as it spreads rapidly between children and carries the highest risk and rate of serious wheezing associated disease. Deaths per year are in the hundreds in the United States.

The tricky part of diagnosing this illness early is realizing that it starts as a common cold before progressing to a lower respiratory tract disease with wheezing and shortness of breath as the hallmark worsening symptoms. Paying close attention for these signs of lower respiratory illness can save a life.

These viral diseases are easily spread via droplets of a cough or nasal secretions. Quarantining young ones and effective hand washing are very important in the prevention of disease. If your child does get ill, bring them to your provider as soon as they show signs of lower tract disease with wheezing, shortness of breath, tugging in their ribs, nasal flaring or fast breathing rate.

Your doctor will likely provide a breathing treatment with a medicine called albuterol which can help in a minority of cases that are asthma related. Children with a family history of asthma are likely to benefit from this medicine and warrant a trial. Other medicines like steroids and antibiotics have no place in treating viral disease and should not be used as the recent scientific literature has proven.

I am often asked the question, "does this mean that we are looking at asthma in the future?"

All things that wheeze are not asthmatic nor will be so. Based on the work of Fernando Martinez, we now understand that children with wheezing concerns can be broken out into 4 categories of disease. From his 2005 paper, "The prevalence of atopy and wheeze by age 16 yr was similar for never and transient wheezers and for persistent and late-onset wheezers. Both transient early, and persistent wheezers had significantly lower FEF25-75 (-259 ml/s, p < 0.001, and -260 ml/s, p = 0.001, respectively), FEV1 (-75 ml, p = 0.02, and -87 ml, p = 0.03, respectively), and FEV1:FVC ratio (-1.9%, p = 0.002, and -2.5%, p = 0.001, respectively) through age 16 yr compared with never wheezers. Late-onset wheezers had levels of lung function similar to those of never wheezers through age 16 yr. There was no significant change in lung function among subjects with any of the four phenotypes, relative to their peers, from age 6 to 16 yr." (Morgan et. al. 2005)

Simply put, if you wheeze below the age of three with viral infections and not in between illness events and you do not have a family history of atopy/asthma, then the odds are very low that you will end up with asthma. If you have a primary relative with asthma, your risks go up. If you have this relative and you wheeze in between viral infections, your risk is even higher over time.

From a micronutrient and disease prevention model, it is clear that vitamin D and zinc are important in the prevention of disease. As with all immune related diseases, vitamin D and zinc are critical for maintaining a robust and normal immune response to disease. Maintaining normal vitamin D levels in a newborn's body is critical. To that end, it is recommended that all breast fed babies receive 400IU of vitamin D daily. Zinc containing foods are a necessary addition to the daily dietary fare for all mother's that are nursing and children that are eating whole foods. Zinc sources.

Exclusive breastfeeding is also critical in order to provide passive antibodies that can prevent illness in the first place throughout the first year of life where the risk is highest.

Aside from the risk of death from this disease, there are some other interesting risks post illness. Children with low vitamin D levels and/or a family history of allergic type diseases are at higher risk for developing later asthma. We also know from the Amish study that children that have little exposure to natural animal based bacteria are at higher risk for allergic type disease.

Take home points:
1) Exclusively breastfeed
2) Maintain adequate vitamin D and zinc levels
3) Get exposed to animal dust of farms/farm houses and household pets
4) Wash hands and avoid people with viral colds when your children are young to prevent infection
5) After 6 months of age, children should eat as healthily as possible to keep all micro nutrient levels normal. No kid friendly foods please!
6) Seek immediate medical help if your child is wheezing, having difficulty breathing, is short of breath or has you concerned
7) Avoid smoke and other airborne pollutants that can reduce immunity and inflame the lung tissue
8) Keep your child hydrated with adequate volumes of breastmilk or supplemental water when older
9) Run a vaporizer with sterile normal saline for mucous thinning and cough reduction
10) Provide chest physical therapy to loosen mucous in the bronchioles - Youtube video on chest PT

 

Breath comfortably,
Dr. M

Morgan Amer J Resp Critical Care Medicine Article