What is the recommended treatment for pediatric patients with allergy-induced asthma or suspected asthma?

Treatment for Allergy-Induced Asthma in Pediatric Patients

Inhaled corticosteroids (ICS) are the preferred first-line treatment for pediatric patients with allergy-induced asthma or suspected asthma, as they provide superior control of symptoms, reduce exacerbations, and improve lung function compared to other medication classes. 1

Initial Assessment and Treatment Selection

• For children with persistent asthma symptoms (more than 3 episodes of wheezing in the past year lasting more than 1 day and affecting sleep), initiation of long-term control therapy is strongly recommended 1
• Risk factors that should prompt treatment include either:
  • Parental history of asthma or physician-diagnosed atopic dermatitis 1
  • Two or more of the following: physician-diagnosed allergic rhinitis, peripheral blood eosinophilia >4%, or wheezing apart from colds 1

Treatment Algorithm by Age Group

Children Under 5 Years

• First-line therapy: Low-dose inhaled corticosteroids via nebulizer, dry powder inhaler (DPI), or metered-dose inhaler (MDI) with holding chamber/face mask 1
• Alternative therapies (if ICS cannot be used):
  • Leukotriene receptor antagonists (LTRAs) such as montelukast (approved for children as young as 12 months for asthma) 1, 2
  • Cromolyn sodium 1

Children 5-11 Years

• First-line therapy: Low-dose inhaled corticosteroids 1
• Alternative therapies:
  • LTRAs (montelukast) 1
  • Cromolyn or nedocromil 1
  • Sustained-release theophylline (less preferred due to side effect profile) 1

Children 12 Years and Older

• First-line options:
  • Daily low-dose ICS with as-needed short-acting beta-agonist (SABA) 1
  • As-needed ICS and SABA used concomitantly 1
• For moderate to severe persistent asthma: ICS-formoterol in a single inhaler as both daily controller and reliever therapy 1

Specific Medication Evidence

• Fluticasone propionate has shown significant improvement in symptoms in children as young as 12 months, with dose-dependent responses (50-100 mcg twice daily) 3
• Budesonide nebulizer solution is FDA-approved for children 1-8 years 1
• Montelukast is effective but less so than ICS, and is FDA-approved for children as young as 12 months for asthma treatment 2
• ICS-LABA combinations (such as fluticasone/salmeterol) provide protection against exercise-induced bronchospasm in children 4 years and older 4, 5

Monitoring and Follow-up

• Assess response to therapy within 4-6 weeks 1
• If clear benefit is not observed within this timeframe, consider alternative therapies or diagnoses 1
• Once control is established and sustained, attempt careful step-down in therapy 1
• Monitor growth in children on ICS therapy, as a mean reduction of approximately 0.5 cm/year in growth velocity may occur during the first year of treatment 6

Special Considerations

• For children with exercise-induced symptoms, consider adding a pre-exercise dose of SABA or using ICS-LABA combination therapy 4
• For children with allergic asthma aged 5 years and older with controlled symptoms, subcutaneous immunotherapy (SCIT) may be considered as an adjunct treatment 1
• For children with frequent exacerbations despite ICS therapy, consider step-up options:
  • Increase ICS dose 1
  • Add LABA for children 4 years and older 1
  • Add LTRA 1

Common Pitfalls and Caveats

• Not all wheezing in young children is asthma; viral respiratory infections are the most common cause of wheezing in preschool-aged children 1
• Growth suppression with ICS appears maximal during the first year of therapy and less pronounced in subsequent years 6
• Underdiagnosis and undertreatment are key problems in young children with asthma 1
• When using ICS, titrate to the lowest effective dose to maintain control while minimizing potential side effects 1

Remember that early recognition and appropriate treatment of high-risk children may result in secondary prevention of childhood asthma and improved long-term outcomes 1.