What is the recommended treatment for pediatric asthma?

Treatment of Pediatric Asthma

Inhaled corticosteroids (ICS) are the preferred first-line controller therapy for persistent asthma in children of all ages, with specific medication choices and dosing based on age and severity of asthma. 1

Stepwise Approach to Treatment Based on Age

Children Under 5 Years

• Mild Persistent Asthma (Step 2):

  • Preferred: Low-dose inhaled corticosteroids (ICS) 2
  • Alternative options: Leukotriene receptor antagonists (LTRAs) like montelukast 2
  • Specific medication: Budesonide nebulizer solution is FDA-approved for ages 1-8 years 2

• Moderate Persistent Asthma (Step 3):

  • Two preferred options:
    1. Medium-dose ICS monotherapy 2
    2. Low-dose ICS plus long-acting β2-agonist (LABA) for children ≥4 years 2
  • Alternative options: Low-to-medium dose ICS plus either LTRA or theophylline (with monitoring) 2

Children 5-11 Years

• Mild Persistent Asthma:

  • Preferred: Low-dose ICS (e.g., fluticasone DPI for ≥4 years) 2, 1
  • Alternative options: Cromolyn, LTRAs, nedocromil, or sustained-release theophylline 2

• Moderate Persistent Asthma:

  • Preferred: Low-dose ICS plus LABA 1
  • Alternative: Medium-dose ICS monotherapy 1

Medication Selection and Administration

Inhaled Corticosteroids

• Advantages:

  • Most effective anti-inflammatory treatment for asthma 3
  • Improve lung function, reduce symptoms and exacerbations 2, 1
  • Strong evidence supports their efficacy in improving long-term outcomes 2

• Administration:

  • For children <4 years: Face mask with nebulizer or MDI with valved holding chamber (VHC) 2
  • For older children: MDI with spacer or dry powder inhaler (DPI) 2
  • After inhalation, rinse mouth with water (without swallowing) to reduce risk of oral candidiasis 4

Leukotriene Receptor Antagonists

• Montelukast considerations:
  • FDA-approved as chewable tablets for ages 2-6 years 2, 5
  • May be considered when inhaler technique is suboptimal 2
  • Less effective than ICS in school-aged children with mild-to-moderate persistent asthma 6
  • About 25% of patients may respond better to montelukast than fluticasone 6

Monitoring and Adjusting Therapy

• Response assessment:

  • Monitor response within 4-6 weeks of initiating therapy 2
  • If no clear benefit is seen within this timeframe, consider alternative therapy or diagnosis 2
  • If benefits are sustained for 2-4 months, attempt step-down therapy 2

• Exacerbation management:

  • For moderate to severe exacerbations: Consider systemic corticosteroids 2
  • For viral-induced exacerbations with history of severe episodes: Consider systemic corticosteroids at onset of viral infection 2

Safety Considerations

• ICS safety profile:

  • At recommended doses, ICS do not have clinically significant or irreversible long-term effects on growth, bone mineral density, ocular toxicity, or adrenal function 2, 3
  • Potential for small, non-progressive reduction in growth velocity is well balanced by effectiveness 2, 3
  • Adrenal insufficiency is rare and primarily occurs with high-dose ICS 3
  • Risk can be minimized by using lowest effective dose and proper inhaler technique 3

• Dose considerations:

  • Side effects of ICS appear to be dose-related 2
  • High doses should be avoided when possible, especially in children with multiple allergic conditions requiring topical corticosteroids 3

Common Pitfalls and Caveats

• Diagnostic challenges: Not all wheeze and cough are caused by asthma; avoid prolonged inappropriate therapy 2
• Age-specific considerations: Children under 5 years often have viral-induced symptoms; many will outgrow wheezing by age 6 2
• Adherence issues: Consider ease of administration when selecting therapy; oral medications like montelukast may have better adherence in some cases 6
• Therapeutic trial approach: In young children, treatment is often a therapeutic trial; discontinue if no response 2
• Combination therapy: Adding adjuvant treatments can reduce the ICS dose required, minimizing systemic exposure 3

When to Consider Specialist Referral

• Difficulties achieving or maintaining control despite appropriate therapy
• Recurrent exacerbations
• Consideration of biologic therapies
• Uncertain diagnosis or atypical presentation

By following this stepwise approach to pediatric asthma management with appropriate medication selection based on age and asthma severity, clinicians can effectively control symptoms, reduce exacerbations, and minimize potential adverse effects.