What is the recommended treatment regimen for asthma in children?

Recommended Treatment Regimen for Asthma in Children

For children with persistent asthma, inhaled corticosteroids (ICS) are the preferred first-line treatment due to their superior efficacy in improving lung function, reducing symptoms, and preventing exacerbations compared to all other medication options. 1, 2

Classification and Initial Assessment

• Asthma severity should be classified as mild persistent (symptoms >2 times/week but <daily) or moderate persistent (daily symptoms requiring daily medication) to guide treatment decisions 2
• Assessment should include evaluation of daytime symptoms, nighttime awakenings, activity limitations, and lung function when age-appropriate 2

First-Line Treatment Recommendations by Age Group

Children 5 Years and Older with Mild Persistent Asthma

• Preferred treatment: Low-dose inhaled corticosteroids 1, 2
• Alternative treatments (listed alphabetically):
  • Leukotriene receptor antagonists (montelukast) 1, 3
  • Cromolyn sodium 1
  • Nedocromil 1
  • Sustained-release theophylline (less preferred due to safety concerns) 1

Children Under 5 Years with Mild Persistent Asthma

• Preferred treatment: Low-dose inhaled corticosteroids delivered via nebulizer, dry powder inhaler (DPI), or metered-dose inhaler (MDI) with holding chamber with or without face mask 1, 2
• Alternative treatments:
  • Leukotriene receptor antagonists (montelukast approved for ages 2+) 1, 3
  • Cromolyn sodium 1

Step-Up Therapy for Moderate Persistent Asthma

Children 5 Years and Older with Moderate Persistent Asthma

• Preferred options:
  • Low-dose inhaled corticosteroids plus long-acting beta2-agonists 1, 2, 4
  • OR medium-dose inhaled corticosteroids 1, 2
• Alternative options:
  • Low-dose inhaled corticosteroids plus leukotriene receptor antagonist 1
  • Low-dose inhaled corticosteroids plus theophylline (with serum level monitoring) 1

Children Under 5 Years with Moderate Persistent Asthma

• Limited data exists comparing treatments for this age group 1
• Options include:
  • Medium-dose inhaled corticosteroids 1, 2
  • Low-dose inhaled corticosteroids plus long-acting beta2-agonists (for children 4+ years) 1, 4

Evidence Supporting ICS as First-Line Treatment

• Strong evidence shows that ICS improve long-term outcomes compared to as-needed beta2-agonists, including:
  • Improved prebronchodilator FEV1 1
  • Reduced airway hyperresponsiveness 1, 2
  • Improved symptom scores 1
  • Fewer courses of oral corticosteroids 1
  • Fewer urgent care visits and hospitalizations 1, 2
• Studies comparing ICS to cromolyn, nedocromil, theophylline, or leukotriene receptor antagonists consistently show ICS to be more effective 1, 2
• Delayed introduction of ICS appears to result in reduced improvement in lung function compared with early use 5

Monitoring and Follow-Up

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

Special Considerations and Caveats

• Safety concerns: ICS at recommended doses have minimal systemic effects on growth, bone mineral density, and adrenal function when used appropriately 2, 7
• Delivery systems: For young children unable to use DPIs or MDIs effectively, nebulized budesonide can be given from 12 months of age 6
• Acute exacerbations: Oral corticosteroids are more effective than inhaled corticosteroids for treating severe acute asthma exacerbations 8
• Viral-induced wheezing: Common in young children and may respond differently to treatment than multiple-trigger wheeze 7
• Undertreatment risk: Inadequate control can lead to permanent airway changes; early intervention with ICS may prevent irreversible airway injury 2, 5
• Compliance challenges: Simplified dosing regimens, proper inhaler technique education, and patient/caregiver education improve treatment adherence 6