What is better for an infant who cannot cough, nebulization with Levolin (levosalbutamol) and budesonide or Syr Ascoril LS Junior (bronchodilator and expectorant)?

Nebulization with Levolin (Levosalbutamol) and Budesonide for Infants Who Cannot Cough

For infants who cannot cough effectively, nebulization with Levolin (levosalbutamol) and budesonide is the preferred treatment option over Syr Ascoril LS Junior due to better safety profile and targeted action on respiratory symptoms. 1

Rationale for Levolin and Budesonide Combination

• Budesonide is the only inhaled corticosteroid with FDA-approved labeling for children under 4 years of age, making it the preferred corticosteroid option for infants 1
• The combination provides both immediate bronchodilation (from levosalbutamol) and anti-inflammatory effects (from budesonide), addressing both components of respiratory distress in infants 1, 2
• For infants who cannot cough effectively, this combination helps improve respiratory mechanics and reduce airway inflammation without requiring the infant to actively cough out secretions 2

Dosing Recommendations

• For infants under 1 year with wheezing, the recommended dose of levosalbutamol nebulizer solution is 0.63 mg/3 mL 1
• The recommended dose of budesonide nebulizer suspension is 0.25-0.5 mg (low daily dose), which can be increased to >0.5-1.0 mg for medium daily dosing if needed 1, 2
• Both medications can be safely administered together in the same nebulizer 1

Administration Technique

• Delivery requires a face mask that should fit snugly over the infant's nose and mouth 1
• Only jet nebulizers should be used because ultrasonic nebulizers are ineffective for suspensions 1
• Avoid nebulizing in the eyes and wash the infant's face after each treatment to prevent local side effects 1

Why Not Syr Ascoril LS Junior?

• Syrup formulations like Ascoril LS Junior (containing expectorants) rely on the child's ability to cough out secretions, which is problematic when the infant cannot cough effectively 3
• Nebulized therapy delivers medication directly to the airways, which is particularly important for infants who cannot effectively clear secretions through coughing 4
• The British Thoracic Society guidelines indicate that for infants who cannot tolerate face masks and spacers, nebulizers are needed, making nebulized therapy more appropriate for infants with poor cough reflex 4

Monitoring and Safety Considerations

• Monitor for potential local side effects including cough, dysphonia, and oral thrush 1
• The safety profile of nebulized budesonide has been well-established, with studies showing no significant effect on hypothalamic-pituitary-adrenal axis function with short (12 weeks) or long (52 weeks) term treatment 2
• Levosalbutamol has shown minimal side effects in pediatric populations, with only rare occurrences of tremor (1%), palpitation (0.9%), and vomiting (0.7%) that are typically mild and transient 3

Important Caveats

• If treating bronchiolitis, be aware that the American Academy of Pediatrics recommends against routine use of corticosteroids, as they have not shown significant clinical benefit in this specific condition 5
• For croup, nebulized budesonide has shown significant improvement in symptoms within the first two hours and may be considered as part of the treatment approach 4, 6
• If no clear benefit is observed within 4-6 weeks of regular treatment, consider alternative therapies or diagnoses 1

Remember that while a metered dose inhaler with spacer is generally preferred for medication delivery in children, nebulizers are specifically indicated when infants cannot effectively use spacers or have difficulty with coughing 4.