Experts establish standardized protocols for pediatric recurrent wheezing diagnosis

Recurrent wheezing, a respiratory disorder, is caused by the narrowing of the airways, mainly affecting children aged less than 5 years. The multifactorial causes of recurrent wheezing have posed a challenge for its diagnosis and treatment. As a result, standardized evidence-based clinical guidelines are not available for pediatricians to manage recurrent wheezing in infants and toddlers.

To fill this knowledge gap, the Committee of Pediatrics, China Medical Education Association, convened a group of experts, including those from pediatric respiratory medicine and allergology, to recommend standardized guidelines for the management of recurrent wheezing in infants and toddlers. These guidelines have been published in the journal Pediatric Investigation on March 5, 2026.

Led by Professor Kunling Shen, a leading pediatric respiratory medicine expert from the National Center for Children's Health, Beijing, and Professor Yunxiao Shang from the Shengjing Hospital of China Medical University, China, the guidelines aim to provide clinicians with standardized protocols to enhance diagnostic accuracy and therapeutic efficacy in managing pediatric patients with recurrent wheezing.

Explaining the rationale for developing these guidelines, Prof. Shen remarked, "Evidence-based guidelines are critical to effectively manage diseases, especially those with multifactorial etiologies, such as recurrent wheezing. The establishment of guidelines can aid pediatricians in uniformly implementing therapeutic and preventive strategies and consequently improving the clinical outcomes of patients."

As a first step toward developing guidelines, two important definitions were established. Recurrent wheezing was defined as three or more wheezing episodes, with each episode separated by a 7-day asymptomatic interval. Meanwhile, infants and toddlers were defined as those aged between 29 days to 3 years. Next, definitions were provided for classifying recurrent wheezing, which were based on the manifestation of symptoms (episodic viral wheezing, multiple trigger wheezing, and unclassified wheezing) and immunological responses (allergic wheezing and non-allergic wheezing), age of onset (transient early wheezing, early-onset persistent wheezing, and late-onset wheezing), and severity (mild wheezing and severe wheezing).

The expert panel recommended various guidelines for diagnosing recurrent wheezing. Clinical history recording and physical examination are the key initial processes for the diagnosis. Laboratory tests (such as eosinophil count and allergen testing), chest imaging, pulmonary function tests, and fractional exhaled nitric oxide analysis were strongly recommended diagnostic investigations. Viral infections are the most common reasons of recurrent wheezing in infants and toddlers. The guidelines also recommend testing for common respiratory pathogens, such as respiratory syncytial virus, rhinovirus, and human metapneumovirus. In addition to viral pathogens, the guidelines emphasize the need for testing for infections due to bacteria such as Streptococcus pneumoniae and Haemophilus influenzae. Other recommended ancillary tests to diagnose recurrent wheezing include esophageal pH testing, bronchoscopy, swallow function assessment, and genetic testing.

The management of recurrent wheezing can also be improved through type 2 inflammatory disease testing, environmental assessment, nutritional assessment, and long-term follow-up plan establishment. According to the proposed guidelines, managing recurrent wheezing is based on the principle of "Evaluation-Diagnosis-Treatment-Re-evaluation-Re-diagnosis." The recommendations for the usage of immunomodulators, vitamin D, probiotics, LTRAs, and antihistamines as prophylactic agents are weak in the guidelines. To predict the prognosis of recurrent asthma, asthma prediction tools and long-term pulmonary function assessments are strongly recommended. Prof. Shang explains the application of these guidelines, "The lack of standard guidelines for managing recurrent wheezing in infants and toddlers has resulted in inconsistent implementation of therapeutic and preventive strategies, leading to poor quality of life. The guidelines developed by us can provide a framework for improving the management of recurrent wheezing in infants and toddlers worldwide."