From the Guidelines
The initial management for a 5-year-old with persistent asthma should include a daily low-dose inhaled corticosteroid (ICS) as controller therapy, such as fluticasone 50-100 mcg twice daily or budesonide 0.5 mg once daily, as recommended by the Expert Panel Report 3 (EPR-3) guidelines 1.
Key Considerations
- This should be administered via a metered-dose inhaler with a valved holding chamber (spacer) and mask if needed for proper delivery.
- A short-acting beta-agonist (SABA) like albuterol 2 puffs every 4-6 hours as needed should be prescribed for rescue therapy during symptom flares.
- Parents should be educated on proper inhaler technique, trigger avoidance (such as dust mites, pet dander, or tobacco smoke), and recognition of worsening symptoms.
- An asthma action plan should be developed and shared with caregivers and school personnel.
- Regular follow-up appointments every 3-6 months are recommended to assess control and adjust therapy as needed.
Rationale
- ICS medications are the preferred first-line treatment because they effectively reduce airway inflammation, which is the underlying pathophysiology of asthma, and have been shown to decrease exacerbations, improve lung function, and reduce symptoms with minimal side effects at appropriate doses 1.
- The benefits of ICSs outweigh any concerns about potential risks of a small, nonprogressive reduction in growth velocity or other possible adverse effects 1.
- High-quality evidence demonstrates the effectiveness of ICS in children 5 to 11 years of age, and comparator studies demonstrate improved control with ICS on a range of asthma outcomes compared to other long-term control medications 1.
From the FDA Drug Label
Use of fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg in patients aged 4 to 11 years is supported by extrapolation of efficacy data from older subjects and by safety and efficacy data from a trial of fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg in children with asthma aged 4 to 11 years The safety and effectiveness of fluticasone propionate and salmeterol inhalation powder in children with asthma younger than 4 years have not been established.
The initial management for a 5-year-old with persistent asthma may include the use of fluticasone propionate and salmeterol inhalation powder 100 mcg/50 mcg, as the safety and efficacy of this medication have been established in children aged 4 to 11 years 2. However, it is essential to monitor the child's growth velocity, as ICS, including fluticasone propionate, may cause a reduction in growth velocity in children and adolescents. The treatment should be titrated to the lowest strength that effectively controls the child's asthma.
From the Research
Initial Management for a 5-year-old with Persistent Asthma
The initial management for a 5-year-old with persistent asthma involves several key components:
- Assessment and Diagnosis: Accurate diagnosis and assessment of asthma severity are crucial for determining the appropriate treatment plan 3.
- Medication: The use of inhaled corticosteroids (ICS) as first-line therapy for children with persistent asthma is recommended, as they are effective in reducing inflammation and improving symptoms 4.
- Bronchodilators: Short-acting beta-2 agonists (SABAs) such as salbutamol are commonly used for acute relief of symptoms, while long-acting beta-2 agonists (LABAs) like salmeterol may be added for patients who require additional control 5, 6.
- Inhalation Devices: The choice of inhalation device can affect the efficacy of medication delivery, with options including metered-dose inhalers (MDIs), dry powder inhalers (DPIs), and nebulizers 3.
Key Considerations
- Growth Effects: Regular use of ICS at low or medium daily doses can be associated with a small reduction in linear growth velocity in children with mild to moderate persistent asthma, although the effect size may vary depending on the ICS molecule and other factors 4.
- Inhalation Sequence: The therapeutic effects of LABAs and ICS are not significantly affected by their inhalation sequence, allowing for flexibility in treatment administration 5.
- Age-Specific Considerations: In children aged 2-5 years, impulse oscillometry can be a useful method for assessing airway responses to bronchoactive drugs, and salmeterol may have a somewhat blunted response compared to albuterol in this age group 6.
Treatment Options
- Salbutamol: A rapid-acting inhaled beta-2 agonist that can be effective in treating mild to moderate acute asthma exacerbations in children, with comparable side effects to nebulization 3.
- Salmeterol: A long-acting beta-2 agonist that can be used in combination with ICS for patients who require additional control, with therapeutic effects that are not significantly affected by inhalation sequence 5.
- Fluticasone: An ICS that can be effective in reducing inflammation and improving symptoms in children with persistent asthma, although regular use may be associated with a small reduction in linear growth velocity 4.