What is the diagnosis and management of pediatric asthma?

From the Guidelines

Asthma in kids should be managed with a stepwise approach to treatment based on symptom severity, with inhaled corticosteroids (ICS) as the preferred long-term control medication for initiating therapy, as recommended by the expert panel report 3 (EPR-3) guidelines 1.

Key Considerations

• For infants and young children with 4 or more episodes of wheezing in the past year, a positive asthma predictive index, and symptoms that affect sleep, daily controller medications such as ICS should be considered to reduce impairment and risk of exacerbations.
• The decision to start long-term daily therapy should be based on consideration of issues regarding diagnosis and prognosis, including the presence of viral respiratory infections, which are the most common cause of asthma symptoms in this age group.
• Selecting medications should take into account the age of the child, with preferred treatment options including ICS budesonide nebulizer solution (1-8 years of age) and ICS fluticasone dry powder inhaler (>4 years of age).

Treatment Approach

• For mild intermittent asthma, a short-acting beta-agonist like albuterol (2 puffs every 4-6 hours as needed) may be sufficient.
• For persistent asthma, daily controller medications such as low-dose ICS (like fluticasone 44-110 mcg twice daily or budesonide 0.5-1mg daily) are necessary.
• Children with moderate to severe asthma may need combination therapy with both ICS and long-acting beta-agonists (like fluticasone/salmeterol).

Monitoring and Follow-up

• Response to therapy should be monitored closely, with a clear and beneficial response expected within 4 to 6 weeks.
• If a clear and beneficial response is not obvious, treatment should be stopped, and alternative therapies or diagnoses should be considered.
• Regular follow-ups with the healthcare provider are essential to adjust treatment as needed and to review the written asthma action plan.

Recent Guidelines

• The European Respiratory Society clinical practice guidelines (2021) recommend a trial of preventer medication with ICS, either alone or in combination with a long-acting β2-agonist (LABA), or leukotriene receptor antagonist (LTRA) to evaluate the response in children with suspected asthma 1.

From the FDA Drug Label

The efficacy of SINGULAIR in pediatric patients 6 to 14 years of age was demonstrated in one 8-week, double-blind, placebo-controlled trial in 336 patients (201 treated with SINGULAIR and 135 treated with placebo) using an inhaled β-agonist on an “as-needed” basis Compared with placebo, treatment with one 5-mg SINGULAIR chewable tablet daily resulted in a significant improvement in mean morning FEV1 percent change from baseline (8.7% in the group treated with SINGULAIR vs 4.2% change from baseline in the placebo group, p<0. 001). SINGULAIR, one 5-mg chewable tablet daily at bedtime, significantly decreased the percent of days asthma exacerbations occurred (SINGULAIR 20.6% vs placebo 25.7%, p≤0. 05). The efficacy of SINGULAIR for the chronic treatment of asthma in pediatric patients 2 to 5 years of age was explored in a 12-week, placebo-controlled safety and tolerability study in 689 patients, 461 of whom were treated with SINGULAIR The findings of these exploratory efficacy evaluations, along with pharmacokinetics and extrapolation of efficacy data from older patients, support the overall conclusion that SINGULAIR is efficacious in the maintenance treatment of asthma in patients 2 to 5 years of age

Asthma in kids can be treated with montelukast (SINGULAIR). The drug has been shown to be effective in pediatric patients aged 6 to 14 years, with significant improvements in FEV1 and reductions in asthma exacerbations. Additionally, exploratory efficacy evaluations support the use of SINGULAIR in pediatric patients aged 2 to 5 years for the maintenance treatment of asthma 2.

• Key benefits of SINGULAIR in pediatric patients include:
  • Improved FEV1
  • Reduced asthma exacerbations
  • Decreased "as-needed" β-agonist use
• Dosage: one 5-mg chewable tablet daily at bedtime for pediatric patients aged 6 to 14 years.

From the Research

Asthma Treatment in Kids

• Asthma is a heterogeneous disease, and it is unrealistic to expect that inhaled corticosteroids (ICS) would be appropriate first-line preventer therapy for all children with asthma 3.
• Leukotriene receptor antagonists (LTRAs) are more effective than ICS for viral-induced wheezing and equivalent to ICS for mild persistent asthma in children, with fewer systemic adverse effects 3.
• LTRAs should be first-line preventer therapy for children with frequent intermittent or mild persistent asthma, while ICS should be reserved for children with moderate to severe persistent asthma 3.

Inhaled Corticosteroids (ICS) and Long-Acting Beta-Agonists (LABAs)

• ICSs and LABAs are recommended treatment options for asthma, with fluticasone propionate and budesonide being common ICSs, and formoterol fumarate and salmeterol xinafoate being common LABAs 4.
• Fluticasone was associated with significantly greater improvement in lung function and better asthma symptom control than budesonide, while formoterol was associated with significantly greater improvement in lung function and better asthma symptom control than salmeterol 4.
• Single inhaler combination regimens (budesonide/formoterol and fluticasone/salmeterol) were frequently more effective in improving treatment outcomes than either monotherapy alone 4.

Treatment Outcomes and Side Effects

• Inhaled fluticasone propionate (FP) is effective in improving lung function, symptom scores, and reducing rescue beta2 agonist use in children and adults with chronic asthma 5.
• FP use is accompanied by an increased likelihood of oropharyngeal side effects, such as sore throat, hoarseness, and oral Candidiasis, which appears to be dose-dependent 5.
• High-dose FP appears to have worthwhile oral-corticosteroid reducing properties, but the risk of growth retardation is lower with fluticasone than budesonide 4.

First-Line Treatment for Asthma

• First-line treatment for asthma is inhaled salbutamol, used on demand to relieve respiratory discomfort or to prevent attacks due to a known trigger, or on a daily basis if necessary, in combination with an inhaled corticosteroid such as beclometasone 6.
• Inhaled corticosteroids should be the first line of treatment for children with asthma, due to their superior efficacy and excellent long-term efficacy and safety profile 7.