What are the guidelines for managing pediatric asthma?

Pediatric Asthma Management Guidelines

The cornerstone of pediatric asthma management is inhaled corticosteroids (ICS) as the mainstay of preventive treatment, combining effectiveness, relative freedom from side effects, and the convenience of twice daily treatment for children with persistent asthma. 1, 2

Diagnosis and Assessment

• Asthma is a chronic inflammatory condition characterized by inflammatory cells, plasma exudation, edema, and smooth muscle hypertrophy, which can be present even in patients with mild asthma 2
• Key diagnostic clues include family history of asthma or atopy, repeated wheeze, recurrent cough (especially at night), and symptoms triggered by viral infections, exercise, allergens, or irritants 1
• In very young children (0-2 years), diagnosis relies almost entirely on symptoms, which may be variable, and other disorders like gastro-esophageal reflux, cystic fibrosis, and chronic lung disease of prematurity may mimic asthma 1

Treatment Goals

• Minimal symptoms during the day and no waking at night 1
• No missed school, full participation in activities and sports 1
• Relatively infrequent need for relief medications 1
• Restoration of normal or best possible long-term airway function 1
• Prevention of severe attacks and enabling normal growth 1

Stepwise Management Approach

Step 1: Mild Intermittent Asthma

• Short-acting beta-agonists (SABAs) as needed for symptom relief 2
• Consider initiating controller therapy if risk factors are present, including parental history of asthma or physician-diagnosed atopic dermatitis 3

Step 2: Mild Persistent Asthma

• Low-dose inhaled corticosteroids as first-line therapy 2, 3
• Alternative options include leukotriene receptor antagonists (LTRAs) such as montelukast, particularly for children under 5 years 3, 4
• Montelukast has shown significant improvement in FEV1 and reduction in as-needed β-agonist use in pediatric patients 6-14 years of age 4

Step 3: Moderate Persistent Asthma

• Medium-dose ICS or low-dose ICS plus long-acting beta-agonist (LABA) for children ≥4 years 3
• Combination therapy with fluticasone propionate and salmeterol has proven effective and safe in children with asthma 5, 6

Step 4-5: Severe Persistent Asthma

• High-dose ICS plus LABA 2
• Consider add-on therapies such as LTRAs, tiotropium, or referral for anti-IgE therapy 3, 7
• Specialist referral is recommended for children with problematic severe asthma 7

Special Considerations

Inhaled Corticosteroids and Growth

• Short-term reductions in growth rate have been shown when inhaled steroids are used at doses greater than 400 μg/day, but these cannot be extrapolated to long-term effects 1, 8
• A small but statistically significant difference in growth velocity has been observed between low doses of ICS and low-to-medium doses, favoring low-dose ICS 8
• Asthma itself delays growth and puberty, but catch-up growth typically occurs 1
• Use the lowest effective dose that provides acceptable control of symptoms 1, 8

Management in Very Young Children (0-2 years)

• Bronchodilator response is variable in the first year of life, but bronchodilators should still be tried 1
• Diagnosis relies on symptoms rather than objective lung function tests 1
• Consider alternative diagnoses in young children with recurrent wheeze 1

Self-Management Education

• Parents and patients should be enabled to manage treatment rather than always consulting a doctor before making changes 1
• Education should include proper inhaler technique, understanding the difference between "relievers" and "preventers," and recognition of worsening symptoms 1
• A written self-management plan should include monitoring of symptoms/peak flow, prearranged actions to take, and when to seek medical attention 1

Key Actions in Self-Management Plans

• Initiation of or increase in inhaled steroid dosage when symptoms worsen 1
• Self-administration of oral steroid tablets when peak flow falls below the predetermined level (usually <60% of normal) 1
• Urgent medical attention when treatment is not working 1

Common Pitfalls and Caveats

• Underdiagnosis and undertreatment are common problems in pediatric asthma 3, 9
• Not all wheezing in young children is asthma; viral respiratory infections are a common cause 3
• Overreliance on bronchodilators without addressing underlying inflammation can lead to increased mortality and morbidity 1, 2
• Poor adherence to inhaled corticosteroids is common; intermittent use is less effective than continuous use for persistent asthma 10, 9
• Physician barriers to prescribing ICS include perceived medication cost, lack of time, and parent hesitancy 9

By following these guidelines and ensuring appropriate use of controller medications, particularly inhaled corticosteroids, most children with asthma can achieve good symptom control and reduce the risk of serious exacerbations.