What is the recommended treatment protocol for asthma in children?

Pediatric Asthma Treatment Protocol

Inhaled corticosteroids (ICS) are the preferred first-line controller medication for children with persistent asthma, with treatment adjusted based on age and asthma severity. 1

Assessment and Classification

First, determine the severity of asthma to guide initial treatment:

• Intermittent asthma: Symptoms ≤2 days/week, nighttime awakenings ≤2x/month, no interference with normal activity
• Mild persistent: Symptoms >2 days/week but not daily, nighttime awakenings 3-4x/month, minor activity limitation
• Moderate persistent: Daily symptoms, nighttime awakenings >1x/week, some activity limitation
• Severe persistent: Symptoms throughout day, frequent nighttime awakenings, extremely limited activity

Age-Specific Treatment Protocols

Children 0-4 Years Old

1. Intermittent Asthma:

   • Short-acting beta-agonist (SABA) as needed

2. Mild Persistent Asthma:

   • Preferred: Low-dose ICS (budesonide nebulizer solution is FDA-approved for ages 1-8 years) 1, 2
   • Alternative: Leukotriene receptor antagonist (LTRA) like montelukast (approved for ages 1+ as granules) 1

3. Moderate Persistent Asthma:

   • Preferred: Medium-dose ICS OR low-dose ICS + LTRA 1

4. Severe Persistent Asthma:

   • Medium-to-high dose ICS + either LABA (for children ≥4 years) or LTRA
   • Consider referral to asthma specialist

Children 5-11 Years Old

1. Intermittent Asthma:

   • SABA as needed

2. Mild Persistent Asthma:

   • Preferred: Low-dose ICS 1
   • Alternative: LTRA, cromolyn, or nedocromil 1

3. Moderate Persistent Asthma:

   • Preferred: Low-dose ICS + LABA 1, 3
   • Alternative: Medium-dose ICS OR low-dose ICS + LTRA 3

4. Severe Persistent Asthma:

   • Medium-to-high dose ICS + LABA
   • Consider adding LTRA or tiotropium
   • Consider referral to asthma specialist

Medication Dosing

Inhaled Corticosteroids (Budesonide)

• Starting doses 2:
  • Previously on bronchodilators alone: 0.5 mg total daily dose (0.25 mg twice daily)
  • Previously on inhaled corticosteroids: 0.5 mg total daily dose
  • Previously on oral corticosteroids: 1 mg total daily dose (0.5 mg twice daily)

Delivery Devices

• Children <4 years: Face mask with nebulizer or MDI with valved holding chamber (VHC) 1
• Children ≥4 years: MDI with VHC, dry powder inhaler, or nebulizer

Acute Asthma Exacerbation Management

For severe asthma exacerbations in children, follow this protocol 1:

1. Immediate Treatment:

   • High-flow oxygen via face mask
   • Salbutamol 5 mg (2.5 mg for very young children) via oxygen-driven nebulizer
   • IV hydrocortisone or oral prednisolone (1-2 mg/kg, max 40 mg)
   • Add ipratropium 100 μg nebulized if needed

2. For Life-Threatening Features (silent chest, cyanosis, poor respiratory effort, altered consciousness):

   • Add IV aminophylline 5 mg/kg over 20 minutes followed by 1 mg/kg/h maintenance
   • Omit loading dose if already on theophylline

3. If Not Improving After 15-30 Minutes:

   • Continue oxygen and steroids
   • Increase frequency of nebulized beta-agonist (up to every 30 minutes)
   • Add ipratropium to nebulizer and repeat every 6 hours

4. Monitoring:

   • Maintain oxygen saturation >92%
   • Monitor PEF before and after treatments
   • Transfer to ICU if deteriorating

Follow-Up and Monitoring

• Review response to therapy every 2-6 weeks initially, then every 1-6 months 1
• Monitor growth in children on ICS (potential 1 cm/year reduction in growth velocity) 2, 4
• Step down therapy once good control is maintained for at least 3 months
• Ensure proper inhaler technique at every visit

Important Considerations

• Growth concerns: While ICS may cause a small, dose-dependent effect on growth velocity (approximately 1 cm in the first year), the benefits outweigh risks when used at appropriate doses 1, 4
• Viral-induced wheezing: In children with primarily viral-triggered symptoms, the response to ICS may be less predictable 1, 5
• Step-up therapy: For children uncontrolled on low-dose ICS, adding LABA is more likely to provide the best response compared to doubling ICS dose or adding LTRA 3
• Delivery devices: Ensure age-appropriate delivery devices and check technique regularly 1

Discharge Criteria After Hospitalization

Before discharge, ensure 1:

• Patient has been on discharge medications for 24 hours
• Inhaler technique has been checked and documented
• PEF >75% of predicted or best
• Treatment plan includes oral steroids (if needed), inhaled steroids, and bronchodilators
• Follow-up with primary care within 1 week and specialist within 4 weeks

By following this protocol and adjusting therapy based on response, most children with asthma can achieve good symptom control and reduce the risk of exacerbations.