What are the GINA (Global Initiative for Asthma) guidelines for managing asthma in children?

GINA Guidelines for Asthma Management in Children

The Global Initiative for Asthma (GINA) guidelines recommend a stepwise approach to asthma management in children, with inhaled corticosteroids (ICS) as the cornerstone of preventive treatment and combination ICS-LABA therapy showing superior outcomes for moderate to severe persistent asthma. 1, 2

Diagnosis of Childhood Asthma

Key diagnostic indicators include:

• Family history of asthma or atopy 3
• Recurrent wheezing episodes 3
• Persistent or recurrent cough, especially at night 3
• Symptoms triggered by viral infections, exercise, emotional disturbances, or exposure to allergens (pets, pollens, dust) 3
• Night time disturbance by wheeze or cough 3

Assessment of Asthma Severity and Control

Assessment should focus on:

• Frequency of daytime and nighttime symptoms 3
• Impact on daily activities and school attendance 3
• Need for rescue medication 3
• Lung function measurements in children ≥5 years old 3
• Growth and development monitoring 3

Stepwise Management Approach

Step 1: Intermittent Asthma

• As-needed short-acting β2-agonist (SABA) for symptom relief 1
• Recent GINA updates recommend against SABA-only treatment due to risks of overuse 1
• Consider low-dose ICS even for intermittent asthma 1

Step 2: Mild Persistent Asthma

• Daily low-dose ICS as first-line controller therapy 1, 4
• Alternative: leukotriene receptor antagonist (LTRA) monotherapy 4

Step 3: Moderate Persistent Asthma (6-11 years)

• Preferred: Low-dose ICS-LABA combination 2
• Alternatives: Medium-dose ICS or low-dose ICS plus LTRA 2
• ICS-LABA shows better outcomes with fewer emergency room visits and hospitalizations compared to medium-dose ICS or ICS-LTRA 2

Step 4-5: Severe Persistent Asthma

• Medium to high-dose ICS-LABA combination 1, 4
• Consider add-on therapies such as LTRA 4
• For severe allergic asthma: Consider omalizumab (anti-IgE) for patients with confirmed IgE-mediated allergic asthma 4

Medication Delivery Considerations

• Most children cannot properly use unmodified metered-dose inhalers (MDIs) 3
• Children using ICS via MDI should use a large volume spacer device to enhance medication deposition 3
• Age-appropriate inhaler devices should be selected 3:
  • 0-4 years: MDI with spacer and mask
  • 5+ years: MDI with spacer or dry powder inhaler if technique is adequate 3
• Nebulizers are often overused and can be replaced by spacer devices in many cases 3

Exacerbation Management

For acute exacerbations:

• Short courses of oral corticosteroids (1-2 mg/kg for 1-5 days) with no tapering needed 3
• Indications for rescue oral steroids include: worsening symptoms, PEF <60% of personal best, sleep disturbance, diminishing response to bronchodilators 3
• Relief treatment can be repeated 2-4 hourly, but failure to respond requires immediate medical assessment 3

Special Considerations for Very Young Children (0-2 years)

• Diagnosis is more challenging and relies almost entirely on symptoms 3
• Recurrent wheeze often associated with viral infections 3
• Bronchodilator response may be variable but should still be tried 3
• Consider alternative diagnoses such as gastroesophageal reflux, cystic fibrosis, or chronic lung disease of prematurity 3

Self-Management Education

GINA emphasizes patient/family education:

• Parents should be enabled to manage treatment without always consulting a doctor 3
• Written action plans should be provided 3
• Education on proper inhaler technique and peak flow monitoring (for children ≥5 years) 3
• Clear distinction between reliever and preventer medications 3
• Regular monitoring of height and weight 3

Growth Concerns with ICS

• Asthma itself can delay growth and puberty, but catch-up growth typically occurs 3
• Use the lowest effective dose of ICS that provides acceptable symptom control 3
• Short-term reductions in growth rate have been observed with ICS doses >400 μg/day, but long-term impact is less clear 3
• Regular monitoring of height and weight is recommended 3

Treatment Outcomes Assessment

Regular assessment should include:

• Days missed from school due to asthma 3
• Frequency of daytime and nighttime symptoms 3
• Frequency of rescue medication use 3
• Activity limitations 3
• Appropriateness of inhaler device and technique 3

The goal of successful management is minimal symptoms, no nighttime awakening, full participation in school and activities, and infrequent need for rescue medication 3.