What is the recommended approach for managing asthma in children?

Stepwise Management of Asthma in Children

The recommended approach for managing asthma in children is a stepwise treatment plan with inhaled corticosteroids (ICS) as the mainstay of preventive treatment for persistent asthma, using the lowest effective dose to maintain control while monitoring growth and development. 1

Diagnosis and Assessment

• Consider family history of asthma/atopy, recurrent wheeze, night-time disturbance, and symptoms triggered by viral infections, exercise, allergens, or cigarette smoke 1
• Key diagnostic clues include:
  • Repeated wheeze and cough
  • Night-time disturbance by symptoms
  • Symptoms precipitated by viral infections, exercise, allergens, or cigarette smoke 2
• Assess severity using:
  • Frequency of daytime and nighttime symptoms
  • Activity limitations
  • Frequency of rescue medication use
  • Days missed from school 2, 1

Stepwise Treatment Approach

Step 1: Intermittent Asthma

• As-needed short-acting beta-agonists (SABA) only
• No daily controller medication needed

Step 2: Mild Persistent Asthma

• Preferred treatment: Low-dose ICS daily 2, 1
• Alternative: Leukotriene receptor antagonist (LTRA) like montelukast, though less effective than ICS 1, 3
• ICS is superior to LTRA for reducing symptoms, preventing exacerbations, and improving lung function 4

Step 3: Moderate Persistent Asthma

• Preferred treatment: Low-to-medium dose ICS plus long-acting beta-agonist (LABA) 2, 1
• Alternative options:
  • Increase ICS to medium-dose range 2
  • Low-to-medium dose ICS plus leukotriene modifier or theophylline 2

Step 4: Severe Persistent Asthma

• Preferred treatment: High-dose ICS plus LABA 2, 1
• For children ≥6 years with allergic asthma not controlled on high-dose ICS plus LABA, consider omalizumab (anti-IgE therapy) 5
• If needed: Add oral corticosteroids (1-2 mg/kg/day, generally not exceeding 60 mg/day) 2

Acute Exacerbation Management

• For acute severe exacerbations:
  • High-flow oxygen via face mask
  • Salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses for very young children)
  • Systemic corticosteroids (IV hydrocortisone or oral prednisolone 1-2 mg/kg/day) 2, 1
  • Consider adding ipratropium bromide 100 mcg nebulized every 6 hours 1

Age-Specific Considerations

Children 0-2 Years

• Diagnosis relies almost entirely on symptoms rather than objective lung function tests
• Bronchodilator response is variable in the first year of life but should still be tried 2
• Viral respiratory infections are major triggers 1

Children 3-5 Years

• For persistent asthma, low-dose ICS is the preferred controller medication
• For moderate-severe episodic viral wheeze, high-dose intermittent ICS may reduce oral corticosteroid use 4

Children 6-11 Years

• Montelukast has shown efficacy in this age group but is less effective than ICS 3
• For severe asthma, omalizumab has shown efficacy in reducing exacerbations 5

Inhaler Technique and Device Selection

• Most children cannot use unmodified metered-dose inhalers (MDIs)
• Use age-appropriate devices:
  • Young children: MDIs with spacers
  • Some children under 5 may use powder inhalers (e.g., Turbohaler, Diskhaler) 2, 1
• Every child using inhaled steroids from an MDI should use a spacer to enhance lung deposition 2

Monitoring and Follow-up

• Monitor height and weight regularly as ICS may affect growth
  • Growth suppression is dose and molecule-dependent
  • Effect is not cumulative beyond the first year of therapy
  • Some catch-up growth may occur while on or off therapy 1, 4
• Assess control at each visit:
  • Days missed from school
  • Daytime and nighttime symptoms
  • Frequency of rescue medication use
  • Activity limitations 2, 1

When to Refer to a Specialist

• Difficulties achieving or maintaining control
• Recurrent exacerbations despite appropriate therapy
• Considering biologic therapies like omalizumab 1, 6
• Before diagnosing severe therapy-resistant asthma, exclude:
  • Poor medication adherence
  • Poor inhaler technique
  • Incorrect diagnosis 6

Common Pitfalls to Avoid

• Overreliance on bronchodilators without addressing underlying inflammation
• Failure to check inhaler technique and adherence before stepping up therapy
• Not using spacers with MDIs in children
• Inadequate monitoring for growth effects with ICS
• Misdiagnosing other conditions as asthma (e.g., foreign body aspiration, vocal cord dysfunction)
• Not addressing environmental triggers and exposures, especially tobacco smoke 2, 1

By following this stepwise approach and regularly reassessing control, most children with asthma can achieve good symptom control and reduce the risk of exacerbations.