What is the first line treatment for managing asthma in children?

Management of Asthma in Children

Inhaled corticosteroids (ICS) are the preferred first-line treatment for managing asthma in children with mild or moderate persistent asthma. 1

Classification and Initial Assessment

• Children with mild persistent asthma show symptoms more than twice weekly but less than daily, with occasional exacerbations that may affect activity 1
• Children with moderate persistent asthma have daily symptoms, require daily medication, and experience exacerbations that affect activity 1
• Severity assessment should include evaluation of daytime symptoms, nighttime awakenings, activity limitation, and lung function when age-appropriate 1

First-Line Treatment Recommendations

For Children 5 Years and Older:

• Low-dose inhaled corticosteroids are the preferred therapy for mild persistent asthma 1
• Alternative therapies (if ICS cannot be used) include leukotriene receptor antagonists (LTRAs), cromolyn, or nedocromil 1
• For moderate persistent asthma, two main options exist:
  • Adding a long-acting beta2-agonist (LABA) to low-dose ICS 1
  • Increasing ICS dose to the medium-dose range 1

For Children Under 5 Years:

• Low-dose inhaled corticosteroids are the preferred therapy delivered via nebulizer, dry powder inhaler, or metered-dose inhaler with holding chamber 1
• Alternative therapies include cromolyn or LTRAs (such as montelukast) 1
• Montelukast is FDA-approved for children as young as 2 years of age 1, 2

Evidence Supporting ICS as First-Line Treatment

• Strong evidence shows that ICS improve long-term outcomes compared to as-needed beta2-agonists, including:

  • Improved lung function (FEV1)
  • Reduced airway hyperresponsiveness
  • Improved symptom scores
  • Fewer courses of oral corticosteroids
  • Fewer urgent care visits and hospitalizations 1

• Studies comparing ICS to cromolyn, nedocromil, theophylline, or LTRAs show that none of these alternatives are as effective as ICS in improving asthma outcomes 1

• In children aged 1-3 years, fluticasone propionate has shown significant dose-related improvements in symptoms and reduction in exacerbations compared to placebo 3

Step-Up Therapy for Inadequate Control

• For children whose asthma is not well controlled on low-dose ICS:

  • For children ≥4 years: Add a LABA (such as salmeterol) to low-dose ICS 1, 4
  • Alternative: Increase ICS dose to medium range 1, 5
  • Less preferred options: Add LTRA or theophylline to low-medium dose ICS 1

• A study in children aged 4-11 years showed that fluticasone propionate 200 mcg twice daily provided greater benefits than 100 mcg twice daily, particularly in children with more severe asthma 5

Monitoring and Follow-Up

• Monitor response to therapy carefully, especially in young children 1
• If benefits are sustained for 2-4 months, attempt to step down therapy 1
• If no clear benefits within 4-6 weeks, consider stopping treatment and exploring alternative therapies or diagnoses 1
• Assess inhaler technique regularly to ensure proper medication delivery 1

Special Considerations for Young Children

• Viral respiratory infections are the most common trigger for asthma symptoms in young children 1
• The decision to start long-term control therapy in very young children should weigh the risks of inadequately controlled asthma against potential medication side effects 1
• For children with recurrent wheezing and positive asthma predictive index, early intervention with ICS may reduce morbidity 1

Common Pitfalls and Caveats

• Undertreatment is a key problem in pediatric asthma management - inadequate control can lead to permanent airway changes 1, 6
• Not all wheezing and cough in children are caused by asthma - avoid prolonged inappropriate therapy 1
• Growth concerns with ICS are minimal at recommended doses and are outweighed by benefits of asthma control 1, 6
• Theophylline is not recommended for young children with mild persistent asthma due to risk of adverse effects, particularly during febrile illnesses 1
• Children with severe attacks may appear distressed; assessment in very young children can be difficult 1

By following these evidence-based recommendations, clinicians can effectively manage asthma in children while minimizing risks and optimizing outcomes related to morbidity, mortality, and quality of life.