Management of a 10-Year-Old Child with Resolved Asthma Exacerbation
The current medications (levocetirizine, montelukast, prednisolone, and salbutamol) should be tapered rather than abruptly discontinued, with prednisolone completed for the full 5-day course, salbutamol continued as needed, and follow-up arranged within 1 month to assess ongoing control. 1
Assessment of Current Status
The child has shown significant improvement with the current treatment regimen:
- Initial symptoms of wheezing, breathlessness, chest pain, and dry cough have alleviated
- Initial lab values showed TLC of 11.8 with 9% eosinophils
- Current lab values show improved TLC of 8.2, though eosinophils remain at 10%
- Initial chest X-ray showed peribronchial thickening
Medication Management Plan
Prednisolone
- Complete the full 5-day course of prednisolone as prescribed (5/15 mg, 6 ml TDS)
- Do not extend beyond 5 days unless symptoms worsen 2, 1
- No tapering is required for short-course prednisolone therapy in children 1
Salbutamol (Albuterol)
- Transition from scheduled use (TDS for 7 days) to as-needed (SOS) basis
- Continue to have salbutamol available for rescue use
- Instruct parents to administer 2 puffs via spacer when symptoms recur 1
Levocetirizine and Montelukast
- Continue levocetirizine 5 mg daily for 2-4 more weeks, then reassess
- Continue montelukast 4 mg daily as maintenance therapy for at least 4 weeks 1
- These medications help manage the allergic component, as suggested by the elevated eosinophil count 3
Follow-up Plan
Short-term (Within 1 Week)
- Assess response to treatment and medication adherence
- Check for any recurrence of symptoms after stopping prednisolone
- Review proper inhaler technique with spacer
Medium-term (Within 1 Month)
- Complete clinical assessment including lung function if available
- Repeat CBC to monitor eosinophil count
- Consider chest X-ray if symptoms have not completely resolved
Monitoring Parameters
- Respiratory rate (target <25/min)
- Oxygen saturation (maintain >95%)
- Presence of wheeze, cough, or chest pain
- Activity tolerance and sleep quality
- Need for rescue salbutamol
Education for Parents
- Recognize early warning signs of asthma exacerbation
- Proper use of inhaler with spacer device
- When to seek urgent medical attention:
- Increased work of breathing
- Inability to complete sentences
- Poor response to salbutamol
- Worsening symptoms despite treatment
Pitfalls and Caveats
Persistent Eosinophilia: The eosinophil percentage remains elevated at 10% despite treatment. This warrants continued monitoring as it may indicate ongoing airway inflammation 4.
Montelukast Considerations: While generally safe, rare cases of pulmonary eosinophilia have been associated with montelukast use 5. Monitor for worsening eosinophilia or new respiratory symptoms.
Abrupt Discontinuation: Avoid stopping all medications simultaneously, as this increases the risk of symptom recurrence. A step-down approach is preferred 1.
Undertreatment: Children with asthma often receive inadequate controller therapy. The presence of eosinophilia suggests potential benefit from continued anti-inflammatory treatment 6.
Combination Therapy: The levocetirizine and montelukast combination has shown efficacy in allergic conditions and may be more effective than monotherapy in persistent allergic symptoms 3.