What is the diagnostic and treatment approach for asthma in a pediatric patient?

From the Guidelines

To diagnose asthma in a pediatric patient, spirometry testing should be used as part of the diagnostic work-up, as recommended by the European Respiratory Society clinical practice guidelines 1. The diagnosis of asthma in children aged 5-16 years involves a combination of clinical evaluation and objective tests.

• A thorough medical history and physical examination are essential to identify symptoms such as recurrent wheezing, coughing, and breathing difficulty.
• Spirometry testing is strongly recommended as part of the diagnostic work-up, with an FEV1/FVC <LLN or <80%, or an FEV1 <LLN or <80% pred considered supportive of an asthma diagnosis 1.
• Other diagnostic tests, such as bronchodilator response (BDR) testing and fractional exhaled nitric oxide (FeNO) measurement, may also be used to support the diagnosis.
• The task force recommends against diagnosing asthma based on symptoms alone, as well as against using an improvement in symptoms following a trial of preventer medication alone to diagnose asthma 1.

For treatment, a stepwise approach is recommended, starting with a short-acting beta-agonist (SABA) like albuterol for mild intermittent asthma.

• For persistent asthma, a low-dose inhaled corticosteroid (ICS) like fluticasone or budesonide should be added, with the option to increase the ICS dose or add a leukotriene modifier like montelukast if symptoms persist.
• Proper inhaler technique and consistent use of a spacer device with a well-fitting mask are essential for effective treatment 1.
• Regular follow-ups every 3-6 months are necessary to adjust treatment as needed and to monitor for potential side effects, such as reduced growth velocity in children treated with ICS 1.
• Creating an asthma action plan with clear instructions for daily management and what to do during flare-ups is also crucial for effective asthma management.

From the FDA Drug Label

The efficacy of SINGULAIR in pediatric patients 6 to 14 years of age was demonstrated in one 8-week, double-blind, placebo-controlled trial in 336 patients (201 treated with SINGULAIR and 135 treated with placebo) using an inhaled β-agonist on an “as-needed” basis The patients had a mean baseline percent predicted FEV1 of 72% (approximate range, 45 to 90%) and a mean daily inhaled β-agonist requirement of 3. 4 puffs of albuterol. Approximately 36% of the patients were on inhaled corticosteroids. Compared with placebo, treatment with one 5-mg SINGULAIR chewable tablet daily resulted in a significant improvement in mean morning FEV1 percent change from baseline (8.7% in the group treated with SINGULAIR vs 4.2% change from baseline in the placebo group, p<0. 001). The efficacy of SINGULAIR for the chronic treatment of asthma in pediatric patients 2 to 5 years of age was explored in a 12-week, placebo-controlled safety and tolerability study in 689 patients, 461 of whom were treated with SINGULAIR SINGULAIR is indicated for the prophylaxis and chronic treatment of asthma in adults and pediatric patients 12 months of age and older.

The diagnostic and treatment approach for asthma in a pediatric patient involves:

• Assessment of asthma severity: based on symptoms, lung function (e.g., FEV1), and medication use
• Treatment with montelukast: a leukotriene receptor antagonist, which has been shown to improve lung function and reduce symptoms in pediatric patients with asthma 2
• Use of inhaled corticosteroids: which may be used concomitantly with montelukast to control asthma symptoms
• Monitoring and adjustment of treatment: to ensure optimal control of asthma symptoms and to minimize the need for rescue medication. Note that the FDA label does not provide a comprehensive diagnostic approach, but rather information on the treatment of asthma with montelukast 2.

From the Research

Diagnostic Approach

• The diagnostic approach for asthma in pediatric patients involves assessing symptoms, medical history, and physical examination 3, 4, 5, 6, 7
• Diagnostic tests such as lung function tests, including spirometry and peak expiratory flow (PEF) measurements, may be used to confirm the diagnosis 4, 5, 6

Treatment Approach

• The treatment approach for asthma in pediatric patients typically involves a stepwise approach, with the goal of achieving and maintaining control of symptoms 3, 4, 5, 6, 7
• For children ≤5 years with asthma or recurrent wheezing, daily low-moderate dose inhaled corticosteroids (ICS) are recommended as the preferred controller, with leukotriene receptor antagonists (LTRA) as alternative therapy 3
• For children older than 4 years with persistent asthma, adding a long-acting beta-2 agonist (LABA) to ICS is recommended as the preferred controller option 4, 5, 6
• Fluticasone propionate/salmeterol (FP/SAL) is an effective treatment option for moderate-to-severe asthma in pediatric patients, with improvements in lung function, symptom control, and reduced risk of exacerbations 5
• The safety profile of FP/SAL is similar to that of fluticasone propionate alone, with a low incidence of adverse events and no significant effects on heart rate, blood pressure, or laboratory variables 6

Treatment Options

• Inhaled corticosteroids (ICS) are the preferred primary long-term treatment for asthmatic children of all age groups 3, 4, 5, 6, 7
• Leukotriene receptor antagonists (LTRA) can be considered as an alternative treatment for mild persistent asthma 3, 7
• Long-acting beta-2 agonists (LABA) can be added to ICS for children older than 4 years with persistent asthma 4, 5, 6
• Montelukast can be effective in some patients, but low-dose inhaled fluticasone is generally more effective in the long-term management of mild to moderate persistent asthma 7