What are the first-line drugs for respiratory disease in pediatrics?

First-Line Drugs for Respiratory Diseases in Pediatrics

For pediatric respiratory diseases, inhaled corticosteroids (ICS) are the preferred first-line therapy for persistent asthma, while amoxicillin is the first-line treatment for community-acquired pneumonia in most cases. 1

Asthma Management

First-Line Therapy for Persistent Asthma

• For children 5 years and older with mild persistent asthma, low-dose inhaled corticosteroids are the preferred therapy 1
• For children younger than 5 years with persistent asthma, low-dose inhaled corticosteroids delivered via nebulizer, dry powder inhaler (DPI), or metered-dose inhaler (MDI) with holding chamber (with or without face mask) are recommended 1
• Alternative therapies for mild persistent asthma include cromolyn, leukotriene receptor antagonists (LTRAs), nedocromil, or sustained-release theophylline 1

Specific ICS Options and Considerations

• Budesonide inhalation suspension (Pulmicort Respules) is the first inhaled corticosteroid approved for nebulizer administration and is approved for children as young as 12 months 2
• Regular use of ICS at low or medium doses is associated with a mean reduction of 0.48 cm/year in linear growth velocity during the first year of treatment, which is less pronounced in subsequent years 3
• The magnitude of growth suppression appears to be more strongly associated with the specific ICS molecule than with the device or dose (within low to medium dose range) 4
• To minimize side effects, the minimal effective ICS dose should be used in children with asthma 4

Pneumonia Management

First-Line Antibiotics for Community-Acquired Pneumonia

• For mild community-acquired pneumonia caused by Streptococcus pneumoniae (most common bacterial cause), amoxicillin (50-75 mg/kg/day in 2 doses) is the preferred oral therapy 1, 5
• For Haemophilus influenzae infections (if β-lactamase negative), amoxicillin (75-100 mg/kg/day in 3 doses) is recommended 1
• For β-lactamase producing H. influenzae, amoxicillin-clavulanate (amoxicillin component 45 mg/kg/day in 3 doses or 90 mg/kg/day in 2 doses) is preferred 1

Atypical Pneumonia Treatment

• For Mycoplasma pneumoniae or Chlamydophila pneumoniae infections, azithromycin is the preferred therapy (10 mg/kg on day 1, followed by 5 mg/kg/day once daily on days 2-5) 1, 6
• Alternative treatments for atypical pneumonia include clarithromycin (15 mg/kg/day in 2 doses) or oral erythromycin (40 mg/kg/day in 4 doses) 1

Acute Asthma Exacerbations

Immediate Treatment for Acute Severe Asthma

• High-flow oxygen via face mask 1
• Salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses for very young children) 1
• Intravenous hydrocortisone 1
• Add ipratropium 100 mg nebulized every 6 hours 1

Life-Threatening Asthma Features Requiring Intensive Care

• PEF <33% predicted or best, poor respiratory effort 1
• Cyanosis, silent chest, fatigue or exhaustion 1
• Agitation or reduced level of consciousness 1

Common Pitfalls and Caveats

• Growth suppression with ICS appears maximal during the first year of therapy and less pronounced in subsequent years, but parents and physicians remain concerned about this side effect 3, 4
• Failure to step down ICS dose to the minimum effective dose once asthma control is achieved may lead to unnecessary side effects 4
• For pneumonia treatment, local patterns of antibiotic resistance should be considered when selecting empiric therapy 1, 5
• Azithromycin should not be used in pediatric patients with pneumonia who are judged to be inappropriate for oral therapy due to moderate to severe illness or risk factors 6
• Penicillin by the intramuscular route remains the usual drug of choice for Streptococcus pyogenes infections and prevention of rheumatic fever, even though azithromycin is often effective 6