What is the recommended steroid inhaled nebulizer treatment for a 2-year-old with asthma, using medications like fluticasone (Flovent) or budesonide (Pulmicort)?

Recommended Steroid Inhaled Nebulizer Treatment for 2-Year-Old with Asthma

For a 2-year-old child with asthma, budesonide inhalation suspension is the preferred inhaled corticosteroid, with FDA approval for children 12 months to 8 years of age at a recommended starting dose of 0.25-0.5 mg twice daily. 1

Medication Options and Dosing

• Budesonide inhalation suspension (Pulmicort Respules) is the only FDA-approved inhaled corticosteroid for children as young as 12 months of age 2, 1
• For children previously on bronchodilators alone: start with 0.5 mg once daily or 0.25 mg twice daily 1
• For children previously on inhaled corticosteroids: 0.5 mg once daily or 0.25 mg twice daily, up to 0.5 mg twice daily 1
• For children previously on oral corticosteroids: 0.5 mg twice daily 1
• In symptomatic children not responding to non-steroidal therapy, a starting dose of 0.25 mg once daily may be considered 1

Administration Technique

• For children under 4 years of age, use a face mask with a nebulizer for proper medication delivery 3
• The face mask should fit snugly over both the nose and mouth to ensure effective delivery 3
• Budesonide suspension is compatible with albuterol, ipratropium, and levalbuterol nebulizer solutions when mixed in the same nebulizer 3
• Use only with compressed air-driven jet nebulizers; not for use with ultrasonic devices 1

Treatment Approach and Monitoring

• Initiate long-term control therapy in children who have had more than three episodes of wheezing in the past year lasting more than 1 day and affecting sleep, especially with risk factors for persistent asthma 3, 2
• Monitor response to therapy closely - if no clear benefit is observed within 4-6 weeks, consider alternative therapies or diagnoses 2
• Once asthma control is established and sustained for 2-4 months, attempt a careful step down in therapy 2, 3
• If once-daily treatment does not provide adequate control, increase to the total daily dose and/or administer as a divided dose 1

Evidence for Efficacy

• Budesonide inhalation suspension has been shown to be effective in long-term clinical studies with infants 2, 4
• Studies demonstrate that both once- and twice-daily dosing of budesonide inhalation suspension (0.25-1 mg) improves pulmonary function and reduces asthma symptoms in young children with persistent asthma 5
• Budesonide has been found to be more effective than nebulized sodium cromoglycate in improving asthma control in young children 4

Safety Considerations

• Most common adverse reactions (incidence >3%) include respiratory infection, rhinitis, coughing, otitis media, viral infection, moniliasis, gastroenteritis, vomiting, diarrhea, abdominal pain, ear infection, epistaxis, conjunctivitis, and rash 1
• Potential local adverse effects include cough, dysphonia, and oral thrush (candidiasis) 3
• Advise parents to rinse the child's mouth or have the child rinse their mouth following inhalation to reduce risk of oral candidiasis 1
• In low-to-medium doses, a small reduction in growth velocity has been observed in children, but this effect may be transient and should be weighed against the benefits of asthma control 3, 6

Alternative Options

• Fluticasone is FDA-approved for children 4 years of age and older, so it is not recommended for a 2-year-old 2
• Montelukast (a leukotriene receptor antagonist) 4 mg chewable tablet is approved for children 2-6 years of age and can be considered as an alternative therapy if inhaled medication delivery is suboptimal due to poor technique or adherence 2
• However, inhaled corticosteroids remain the preferred first-line therapy for persistent asthma in this age group 2

Special Considerations

• For recurrent wheezing triggered by respiratory infections with no symptoms between infections, consider 1 mg twice daily for 7 days at the first sign of respiratory infection 3
• This approach may be beneficial for children who have had three or more episodes of wheezing triggered by respiratory infections 3
• The benefits of inhaled corticosteroids outweigh the potential risks of a small reduction in growth velocity or other possible adverse effects 2, 6