What is the recommended dosage and administration of inhaled corticosteroids (ICS) for children less than or equal to 2 years old?

Inhaled Corticosteroid Dosing for Children ≤2 Years Old

Budesonide nebulizer solution is the only FDA-approved inhaled corticosteroid (ICS) for children under 4 years of age, with recommended dosing of 0.25-0.5 mg daily for low dose and >0.5-1.0 mg daily for medium dose. 1, 2

Approved ICS Options for Young Children

For children ≤2 years old with persistent asthma requiring controller therapy:

• First-line option: Budesonide nebulizer suspension

  • Low dose: 0.25-0.5 mg daily
  • Medium dose: >0.5-1.0 mg daily
  • Administration: Via jet nebulizer (not ultrasonic nebulizers) 1

• Alternative option (for children ≥1 year): Fluticasone HFA/MDI

  • Low dose: 176 mcg daily
  • Medium dose: >176-352 mcg daily
  • Administration: Must use face mask that fits snugly over nose and mouth 1

Administration Considerations

• Children <4 years generally require delivery of ICS through a face mask that should fit snugly over nose and mouth
• Avoid nebulizing in the eyes
• Wash face after each treatment to prevent local side effects
• For budesonide suspension:
  • May be administered twice daily
  • Compatible with albuterol, ipratropium, and levalbuterol nebulizer solutions
  • Use only jet nebulizers (ultrasonic nebulizers are ineffective for suspensions) 1
• For fluticasone HFA:
  • Divide dose twice daily
  • Low dose for children <4 years is higher than for children 5-11 years due to lower dose delivered with face mask 1

Monitoring and Adjusting Therapy

• Monitor response to therapy on multiple clinical parameters
• Once asthma control is achieved, carefully titrate to minimum dose required to maintain control 1
• If benefits are sustained for 2-4 months, attempt a step down in therapy
• If no clear benefits within 4-6 weeks, stop treatment and consider alternative therapies or diagnoses 1

Safety Considerations

Potential Local Side Effects

• Cough
• Dysphonia
• Oral thrush (candidiasis)

Minimizing Side Effects

• Use spacer or valved holding chamber with non-breath-actuated MDIs
• Ensure mouthwashing and spitting after inhalation
• Wash face after each treatment 1

Systemic Safety

• The safety and efficacy of ICS in children <1 year has not been established 1
• In low-to-medium doses, ICS therapy is generally safe with minimal systemic effects 3, 4
• High doses may potentially affect adrenal function, growth, and bone mass, though clinical significance is limited when used appropriately 3
• Adrenal insufficiency is rare and primarily confined to children receiving high doses of ICS 5, 3

Common Pitfalls to Avoid

1. Using ultrasonic nebulizers for budesonide suspension - Only jet nebulizers are effective for suspensions 1

2. Inadequate face mask fit - Ensure snug fit over nose and mouth to maximize drug delivery 1

3. Failure to wash face after treatment - Can lead to local side effects 1

4. Not monitoring response - Essential to evaluate effectiveness within 4-6 weeks and adjust therapy accordingly 1

5. Inappropriate dosing - Use the lowest effective dose to minimize potential systemic effects 3

6. Overlooking concomitant topical corticosteroids - Consider total corticosteroid exposure from all sources 3

ICS remain the most effective anti-inflammatory treatment for persistent asthma in young children, with benefits clearly outweighing potential adverse effects when used appropriately 3, 4.