When should a child be prescribed budesonide (corticosteroid)?

Budesonide Treatment Recommendations for Children

Budesonide inhalation suspension is indicated for maintenance treatment of asthma and prophylactic therapy in children 12 months to 8 years of age with persistent asthma. 1

Primary Indications for Budesonide in Children

• Persistent Asthma: FDA-approved for children 1-8 years of age as maintenance therapy 2, 1
• Croup: 500 μg as a single or repeated dose may be effective for symptom reduction in the first two hours 3
• Bronchopulmonary Dysplasia (BPD): May improve lung mechanics and short-term outcomes in neonates, though evidence is limited 2, 4

Dosing Recommendations by Condition

For Persistent Asthma:

• Initial dosing based on previous therapy: 1
  • Children on bronchodilators alone: 0.5 mg once daily or 0.25 mg twice daily
  • Children on inhaled corticosteroids: 0.5 mg once daily or 0.25 mg twice daily up to 0.5 mg twice daily
  • Children on oral corticosteroids: 0.5 mg twice daily
• For symptomatic children not responding to non-steroidal therapy: Starting dose of 0.25 mg once daily may be considered 1

For Viral-Induced Wheeze:

• Children under 4 years: 0.25-0.5 mg twice daily 3
• For recurrent wheezing triggered by respiratory infections: 1 mg twice daily for 7 days at first sign of infection 5

For Croup:

• 500 μg as a single dose or repeated dose 3

When to Initiate Therapy

• Initiate long-term control therapy in children who have had more than 3 episodes of wheezing in the past year that lasted more than 1 day and affected sleep AND who have risk factors for developing persistent asthma 2, 5
• Risk factors include: physician diagnosis of atopic dermatitis, parental history of asthma, physician-diagnosed allergic rhinitis, >4% peripheral blood eosinophilia, or wheezing apart from colds 2
• For children with viral respiratory infections causing severe exacerbations but no symptoms between episodes (low impairment but high risk), budesonide may be appropriate 2

Administration Considerations

• Use only with jet nebulizers connected to an air compressor; not for use with ultrasonic devices 1
• For children under 4 years, delivery requires a face mask that should fit snugly over nose and mouth 3, 5
• Budesonide suspension is compatible with albuterol, ipratropium, and levalbuterol nebulizer solutions in the same nebulizer 3

Monitoring and Follow-up

• Monitor response to therapy closely; if no clear benefit is observed within 4-6 weeks, stop treatment and consider alternative therapies or diagnoses 2, 5
• Once asthma control is established and sustained, attempt a careful step down in therapy to find the minimum effective dose 5, 1
• Monitor for potential adverse effects including oral thrush, cough, and dysphonia 5
• In children, monitor growth as inhaled corticosteroids may cause a small, nonprogressive reduction in growth velocity 2

Special Considerations

• Budesonide is not indicated for relief of acute bronchospasm or status asthmaticus 1
• For children whose asthma is not well controlled on low-dose inhaled corticosteroids, consider adding a non-corticosteroid long-term control medication before increasing to high-dose to avoid potential side effects 2
• Children in this age group have high rates of spontaneous remission of symptoms, so regular reassessment is important 2

Common Pitfalls and Caveats

• Not all wheeze and cough are caused by asthma; caution is needed to avoid inappropriate, prolonged therapy 2
• Rinse the child's mouth after inhaled corticosteroid use to prevent oral candidiasis 2
• Budesonide should not be used for acute symptom relief; always have a short-acting beta2-agonist medicine (rescue inhaler) available 1
• Be aware that most young children who wheeze with viral respiratory infections experience symptom remission by 6 years of age 2

By following these evidence-based recommendations, clinicians can optimize the use of budesonide in pediatric patients while minimizing potential adverse effects.