What are the recommendations for pediatric asthma management according to Global Initiative for Asthma (GINA) guidelines?

GINA Guidelines for Pediatric Asthma Management

According to the Global Initiative for Asthma (GINA) guidelines, pediatric asthma management should follow a stepwise approach with inhaled corticosteroids (ICS) as the cornerstone of controller therapy for persistent asthma, with treatment adjustments based on symptom control and risk factors. 1, 2

Definition and Assessment

Definition of Asthma Exacerbation

• GINA defines asthma exacerbations as "episodes of acute or subacute worsening in symptoms and lung function" 1
• Requires a change in treatment and monitoring for deterioration

Assessment Parameters

• Vital signs: Pulse rate, respiratory rate, oxygen saturation (target 92-95%)
• Clinical signs: Use of accessory muscles, degree of breathlessness, wheezing, agitation, level of consciousness
• Objective measurements:
  • Pulse oximetry (recommended in 11 guidelines)
  • Peak expiratory flow (PEF) monitoring
  • Spirometry with bronchodilator reversibility testing for diagnosis 1

Asthma Control Categories

• Well-controlled: Symptoms ≤2 days/week, nighttime awakenings ≤1/month, no activity limitation, rescue medication use ≤2 days/week 2
• Not well-controlled: More frequent symptoms, some activity limitation
• Very poorly controlled: Continuous symptoms, frequent nighttime awakenings, extreme activity limitation

Stepwise Management Approach

Step 1 (Mild Intermittent Asthma)

• Ages 12+ years: Either daily low-dose ICS and as-needed SABA, or as-needed ICS and SABA used concomitantly 1, 3
• Ages 6-11 years: As-needed SABA with consideration of low-dose ICS

Step 2 (Mild Persistent Asthma)

• All pediatric ages: Daily low-dose ICS plus as-needed SABA 2
• Alternative: Leukotriene receptor antagonist (LTRA), particularly for viral-induced wheezing 4

Step 3 (Moderate Persistent Asthma)

• Ages 6-11 years: Options include 5:
  1. Low-dose ICS-LABA (preferred based on evidence)
  2. Medium-dose ICS
  3. Low-dose ICS plus LTRA

Step 4-5 (Severe Persistent Asthma)

• All pediatric ages: Medium/high-dose ICS-LABA
• Ages 5+ years: Consider add-on therapies:
  • Long-acting muscarinic antagonist (LAMA) for ages 12+ 1
  • Subcutaneous allergen immunotherapy (SCIT) for allergic asthma 1
  • Biologics (e.g., omalizumab) for severe allergic asthma with elevated IgE 6

Medication Recommendations

Controller Medications

• ICS: First-line controller for persistent asthma
  • Common options: fluticasone, budesonide, beclomethasone, ciclesonide
  • Note: ICS may cause small reduction in growth velocity (0.48 cm/year) during first year of treatment 7

Reliever Medications

• SABA: Albuterol/salbutamol for quick relief
• ICS-formoterol: Can be used as both maintenance and reliever therapy in a single inhaler for ages 12+ 3

Add-on Therapies

• LABA: Added to ICS for inadequate control (preferred over LAMA) 1
• LTRA: Alternative add-on, especially for allergic or viral-triggered asthma
• Ipratropium bromide: Recommended for acute exacerbations in combination with SABA 1

Management of Exacerbations

Mild-Moderate Exacerbations

• SABA via spacer/nebulizer (4-8 puffs every 20 minutes for up to 3 doses, then every 1-4 hours as needed) 2
• Consider short course of oral corticosteroids if not responding to SABA

Severe Exacerbations

• Oxygen supplementation (target saturation 92-95%) 1
• Frequent SABA (nebulized or via spacer)
• Systemic corticosteroids (oral or IV)
• Consider ipratropium bromide in combination with SABA 1

Monitoring and Follow-up

Regular Assessment

• Monitor frequency of SABA use (>2 times/week indicates poor control) 2
• Schedule follow-up within 1-4 weeks after treatment changes 2
• Assess inhaler technique at every visit

Indicators for Specialist Referral

• Difficulties achieving or maintaining control
• Recurrent exacerbations despite appropriate therapy
• Consideration of biologic therapies

Prevention Strategies

Environmental Control

• Multicomponent allergen-specific mitigation for children with confirmed allergies 1
• Avoidance of tobacco smoke exposure (50% risk reduction) 2
• Annual influenza vaccination for children >6 months 2

Education

• Proper inhaler technique with spacer device
• Differentiation between reliever and controller medications
• Written asthma action plan
• Recognition of worsening symptoms and when to seek medical attention

Key Pitfalls to Avoid

• Treating with SABA alone without controller medication
• Inadequate assessment of control and risk factors
• Poor inhaler technique
• Lack of a written asthma action plan
• Failure to address environmental triggers
• Overlooking growth monitoring in children on ICS

By following these GINA guidelines, clinicians can optimize asthma management in pediatric patients, reducing exacerbations and improving quality of life while minimizing medication side effects.