Repetitive wheezing, a breathing disorder, is caused by narrowing of the airways, mostly affecting children under the age of 5. 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 on Pediatrics, China Medical Education Association, convened a panel of experts, including experts from pediatric respiratory medicine and allergology, to propose standardized guidelines for the management of recurrent wheezing in infants and toddlers. These guidelines have been published in the Journal Pediatric Research on March 5, 2026.
Led by Professor Kunling Shen, a leading expert in pediatric respiratory medicine from the National Center for Children’s Health, Beijing, and Professor Yunxiao Shang from Shengjing Hospital, China Medical University, the guidelines aim to provide clinicians with standardized protocols to improve diagnostic accuracy and repeat patient treatment.
Explaining the rationale for developing these guidelines, Professor Shen remarked, “Evidence-based guidelines are critical for effective disease management, especially those with multifactorial etiologies, such as recurrent wheezing. The establishment of guidelines can help pediatricians to uniformly apply therapeutic and preventive strategies and consequently improve clinical outcomes for patients.”
As a first step towards developing guidelines, two important definitions were established. Recurrent wheezing was defined as three or more episodes of wheezing, with each episode separated by an asymptomatic interval of 7 days. Meanwhile, infants and toddlers were defined as those aged between 29 days and 3 years. Definitions were then given for the classification of recurrent wheezing, which were based on symptom onset (episodic viral wheezing, multi-cause wheezing, and unclassified wheezing) and immunological responses (allergic versus nonallergic wheezing), age of onset (transient early wheezing, early wheezing, wheezing), and severity (mild wheezing and severe wheezing).
The expert panel recommended several guidelines for the diagnosis of recurrent wheezing. Taking a clinical history and physical examination are the basic initial procedures for diagnosis. Laboratory tests (such as eosinophil count and allergen testing), chest imaging, pulmonary function tests, and fractional exhaled nitric oxide analysis are strongly recommended for diagnostic investigations. Viral infections are the most common reasons for 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 for the diagnosis of recurrent wheezing include esophageal pH testing, bronchoscopy, evaluation of swallowing function, and genetic testing.
Management of recurrent wheezing can also be improved through type 2 inflammatory disease testing, environmental assessment, nutritional assessment, and establishing a long-term follow-up plan. According to the proposed guidelines, the management of recurrent wheezing is based on the principle of “Assessment-Diagnosis-Treat-Re-Assessment-Re-Evaluation”. Recommendations for the use of immunomodulators, vitamin D, probiotics, LTRAs and antihistamines as prophylactic agents are weak in the guidelines. Asthma prediction tools and long-term lung function assessments are strongly recommended to predict the prognosis of recurrent asthma. Professor Shang explains the application of these guidelines, “The lack of standard guidelines for the management of recurrent wheezing in infants and toddlers has led to inconsistent application of therapeutic and preventive strategies, leading to poor quality of life. The guidelines we developed can provide a framework for improving the management of recurrent wheezing in infants and toddlers worldwide.”
