Management of Pediatric Asthma
Inhaled corticosteroids (ICSs) are the preferred first-line treatment for persistent asthma in children of all ages due to their superior efficacy in suppressing airway inflammation, with benefits that outweigh potential risks. 1
Diagnosis and Assessment
Diagnosis should be based on:
- Clinical history of recurrent episodes of wheezing, coughing, or breathing difficulty
- Family history of asthma or atopy
- Objective testing with spirometry showing bronchodilator reversibility (when age-appropriate)
- Peak expiratory flow (PEF) monitoring
Asthma severity assessment should include:
- Symptom frequency
- Activity limitations
- Rescue medication use
- Lung function measurements (when age-appropriate)
Treatment Approach by Age and Severity
Children <5 Years
- Mild Intermittent Asthma: As-needed SABA
- Persistent Asthma: Daily low-dose ICS (preferred: budesonide nebulizer solution) 1
- Alternative Treatment: Leukotriene receptor antagonists (LTRAs) may be considered if ICS administration is challenging, though they are less effective than ICS 2
Children 5-11 Years
- Mild Intermittent Asthma: As-needed SABA
- Mild Persistent Asthma: Low-dose ICS (preferred: fluticasone DPI 100-200 mcg/day) 1
- Moderate Persistent Asthma: Either:
- Medium-dose ICS (up to 500 mcg/day fluticasone equivalent)
- Low-dose ICS + LABA (preferred over doubling ICS dose) 3
Children ≥12 Years
- Treatment follows similar patterns to younger children but with age-appropriate dosing
- For moderate-severe persistent asthma, combination therapy with ICS + LABA is preferred 2
Management of Acute Exacerbations
Assessment of Severity
Severe Exacerbation Signs:
Life-threatening Features:
Immediate Treatment
- High-flow oxygen to maintain SaO₂ >92%
- Frequent short-acting β-agonist (salbutamol 5 mg or terbutaline 10 mg) via oxygen-driven nebulizer
- Systemic corticosteroids (prednisolone 1-2 mg/kg/day, maximum 40 mg)
- Consider adding ipratropium bromide 100 mcg nebulized every 6 hours 2, 1
For Life-threatening Exacerbations
- Add intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion (1 mg/kg/h)
- Omit loading dose if already on oral theophyllines 2
Step-Up/Step-Down Approach
- Start with appropriate initial therapy based on severity assessment
- Assess control regularly (symptoms, exacerbations, lung function)
- Step up if control is inadequate:
- For children on low-dose ICS with inadequate control, adding a LABA is more effective than doubling the ICS dose 3
- Step down when good control is maintained for at least 3 months
Prevention and Education
- Annual influenza vaccination for all asthmatic children >6 months
- Allergen avoidance measures for identified triggers
- Avoidance of tobacco smoke exposure
- Written asthma action plan including:
- Daily controller medications
- How to recognize worsening symptoms
- When and how to adjust medications
- When to seek urgent medical care 1
Follow-up Recommendations
- Schedule follow-up within 1 week after hospital discharge
- Review inhaler technique at every visit
- Monitor frequency of SABA use
- Assess for side effects of medications
- Consider referral to asthma specialist for:
- Difficulties achieving or maintaining control
- Recurrent exacerbations despite appropriate therapy
- Consideration of biologic therapies 1
Special Considerations
- At recommended low to medium doses, ICS have a wide safety margin in children
- High doses may potentially affect bone mineral density and cause cataract formation, but this is rare at standard pediatric doses 1
- For children unable to use ICS properly, LTRAs may be considered as an alternative, though they are less effective than ICS 2, 4
- Children with markers of allergic inflammation (high exhaled nitric oxide, eosinophilia, elevated IgE) respond better to ICS than to LTRAs 5