What are the best inhaled corticosteroids (ICS) for asthma in a 3-year-old child?

From the Guidelines

For a 3-year-old with asthma, the preferred inhaled corticosteroid (ICS) is typically low-dose fluticasone propionate (Flovent) at 50-100 mcg twice daily or budesonide (Pulmicort) at 0.25-0.5 mg once or twice daily, as these medications have been shown to reduce airway inflammation and improve symptom control in young children with asthma 1.

Key Considerations

• The decision to initiate long-term control therapy should be based on the child's symptoms, risk factors, and response to treatment, with careful consideration of the potential benefits and risks of medication therapy 2.
• Inhaled corticosteroids are the preferred long-term control medication for initiating therapy in young children with asthma, due to their effectiveness in reducing airway inflammation and improving symptom control 3.
• The choice of ICS should be based on individual drug efficacy studies and the child's age and ability to use the delivery device, with budesonide nebulizer solution and fluticasone dry powder inhaler being FDA-approved options for young children 2.

Delivery and Monitoring

• Medications should be delivered using an age-appropriate spacer device with a mask attachment to ensure proper medication delivery 2.
• Treatment should be adjusted based on symptom control, with regular follow-up every 3-6 months with a pediatrician or pediatric pulmonologist 3.
• Parents should monitor for side effects such as oral thrush, which can be prevented by rinsing the child's mouth or giving them a drink after each use 3.

Alternative Therapies

• Montelukast (Singulair) at 4 mg once daily in the evening may be added as an alternative or complementary therapy for young children with asthma, although its effectiveness may vary depending on the individual child's response 3.
• Other long-term control medications, such as leukotriene receptor antagonists (LTRAs) and long-acting beta2-agonists (LABAs), may be considered for step-up therapy in children whose asthma is not well controlled on low-dose ICS, although the evidence for their use in young children is limited 2.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Inhaled Corticosteroids for Asthma in Children

• The most effective inhaled corticosteroids (ICS) for asthma in children are still being researched, but some studies suggest that fluticasone propionate may be a good option 4, 5, 6.
• A study comparing fluticasone propionate to beclomethasone dipropionate in children with asthma found that fluticasone propionate was at least as effective and well-tolerated as beclomethasone dipropionate 4.
• Another study found that fluticasone propionate had a higher topical anti-inflammatory potency than beclomethasone dipropionate and was effective in treating asthma in children 5.
• A review of fluticasone propionate found that it was a potent inhaled corticosteroid for the treatment of asthma, with efficacy documented across the entire spectrum of asthma severity, including corticosteroid-dependent disease 6.

Dosage and Administration

• The optimal starting dose of ICS for asthma in children is not clearly established, but a review of studies found that commencing with a moderate dose ICS is equivalent to commencing with a high dose ICS and down-titrating 7.
• The same review found that initial moderate ICS dose appears to be more effective than initial low ICS dose, and that high dose ICS may be more effective than moderate or low dose ICS for airway hyperresponsiveness 7.
• There is no benefit in doubling or quadrupling ICS in subjects with stable asthma 7.

Specific ICS Options

• Fluticasone propionate is available in both aerosolised metered dose inhaler (MDI) and dry powder devices, with dosages ranging from 44-500 micrograms/puff 6.
• Beclomethasone dipropionate and budesonide are also options for ICS treatment, but may not be as effective as fluticasone propionate in some cases 4, 5.
• The combination of ICS and long-acting beta2-agonists (LABAs) may be more efficacious than adding a short-acting beta2-agonist or an antileukotriene, but there is limited data on this in children 8.