What is the classification and management of pediatric asthma?

Pediatric Asthma Classification and Management

Pediatric asthma should be classified based on symptom frequency, nighttime awakenings, activity limitations, and rescue medication use, with treatment following a stepwise approach that prioritizes inhaled corticosteroids as first-line controller therapy for persistent asthma. 1

Classification of Pediatric Asthma

Asthma control in children is categorized into three levels based on specific criteria:

For Children 0-4 years:

• Well-controlled:

  • Symptoms ≤2 days/week
  • Nighttime awakenings ≤1 time/month
  • No interference with normal activity
  • Short-acting β2-agonist use ≤2 days/week
  • 0-1 exacerbations requiring oral corticosteroids per year 2

• Not well-controlled:

  • Symptoms >2 days/week
  • Nighttime awakenings >1 time/month
  • Some limitation in normal activity
  • Short-acting β2-agonist use >2 days/week
  • 2-3 exacerbations requiring oral corticosteroids per year 2

• Very poorly controlled:

  • Symptoms throughout the day
  • Nighttime awakenings >1 time/week
  • Extreme limitation in normal activity
  • Short-acting β2-agonist use several times per day

  • 3 exacerbations requiring oral corticosteroids per year 2

For Children 5-11 years:

Additional assessment includes lung function measurements:

• Well-controlled:

  • FEV1 or peak flow >80% of predicted/personal best
  • FEV1/FVC >80% 2

• Not well-controlled:

  • FEV1 or peak flow 60-80% of predicted/personal best
  • FEV1/FVC 75-80% 2

• Very poorly controlled:

  • FEV1 or peak flow <60% of predicted/personal best
  • FEV1/FVC <75% 2

Diagnostic Approach

Key diagnostic clues for pediatric asthma include:

• Family history of asthma or atopy
• Repeated wheeze and cough
• Night-time disturbance by wheeze or cough
• Symptoms triggered by:
  • Viral infections
  • Exercise or excitement
  • Allergens (pets, pollens, dust)
  • Cigarette smoke 2, 1

Management of Chronic Asthma

Treatment follows a stepwise approach based on the level of control:

Step 1: Intermittent Asthma

• Short-acting β2-agonist (SABA) as needed 1

Step 2: Mild Persistent Asthma

• Preferred: Low-dose inhaled corticosteroids (ICS) daily
• Alternative: Leukotriene modifier (e.g., montelukast) 1, 3

Step 3: Moderate Persistent Asthma

• Preferred: Low-to-medium dose ICS plus long-acting β2-agonist (LABA)
• Alternative: Medium-dose ICS or low-dose ICS plus leukotriene modifier 1

Step 4: Severe Persistent Asthma

• Preferred: Medium-to-high dose ICS plus LABA
• Alternative: High-dose ICS plus either leukotriene modifier or theophylline 1

Step 5: Very Severe Persistent Asthma

• High-dose ICS plus LABA plus oral corticosteroids
• Consider omalizumab for children ≥6 years with allergic asthma not controlled on high-dose ICS plus LABA 1

Age-Specific Medication Considerations

• Children <5 years: Budesonide nebulizer solution is preferred ICS
• Children ≥5 years: Fluticasone DPI is an appropriate ICS option
• Children ≥4 years: Salmeterol DPI can be considered for inadequate control 1

Management of Acute Exacerbations

Assessment of Severity

Signs of severe exacerbation include:

• Too breathless to talk or feed
• Respiratory rate >50 breaths/min
• Heart rate >140 beats/min
• Peak flow <50% predicted 1

Life-threatening features include:

• Peak flow <33% predicted
• Cyanosis
• Silent chest
• Fatigue
• Reduced consciousness 1

Treatment of Acute Exacerbations

1. Oxygen: High-flow via face mask to maintain SpO2 >94%
2. Short-acting β2-agonist: Salbutamol or terbutaline via oxygen-driven nebulizer
3. Systemic corticosteroids:
   • Oral prednisolone 1-2 mg/kg (maximum 60 mg) for 1-5 days
   • No tapering needed for short courses 2, 1
4. Consider adding: Ipratropium bromide 100 mcg nebulized every 6 hours for severe exacerbations 1

Rescue Courses of Oral Corticosteroids

Indications for "rescue" oral steroids include:

• Progressive worsening of symptoms day by day
• Peak flow <60% of patient's best
• Sleep disturbed by asthma
• Morning symptoms persisting until midday
• Diminishing response to inhaled bronchodilators 2

Device Selection and Technique

• Most children cannot use standard metered-dose inhalers (MDIs) effectively
• Preferred devices:
  • MDIs with spacers for all ages
  • Powder inhalers (e.g., Turbohaler, Diskhaler) for older children
• Every child using inhaled steroids should use a spacer with their MDI to enhance lung deposition 1

Monitoring and Follow-up

• Assess control every 1-6 months based on severity
• Monitor height and weight regularly due to potential growth effects of ICS
• Consider stepping down therapy after 3 months of good control 1

Prevention and Education

• Annual influenza vaccination for all asthmatic children >6 months
• Strict avoidance of tobacco smoke exposure
• Patient/parent education should include:
  • Proper inhaler technique
  • Difference between "relievers" and "preventers"
  • Recognition of worsening symptoms
  • When to seek urgent medical attention 1

Referral Criteria

Refer to an asthma specialist when:

• Difficulties achieving or maintaining control
• Recurrent exacerbations despite appropriate therapy
• Considering biological therapies like omalizumab 1

Common Pitfalls to Avoid

• Underdiagnosis and undertreatment of pediatric asthma
• Inadequate assessment of control
• Poor inhaler technique
• Failure to step up therapy when control is not achieved
• Failure to address environmental triggers
• Overreliance on rescue medications rather than controller therapy
• Not providing written asthma action plans