What is the management approach for childhood asthma?

Childhood Asthma Management

Childhood asthma requires a stepwise pharmacologic approach centered on inhaled corticosteroids as the cornerstone of anti-inflammatory therapy, combined with patient/family education, environmental trigger avoidance, and regular monitoring to achieve minimal symptoms, normal activity, and optimal growth. 1, 2

Diagnosis and Recognition

Childhood asthma is common and frequently underdiagnosed, with symptoms developing in 50% of children by age 3 and 80% by age 5. 1 Key diagnostic clues include:

• Family history of asthma or atopy 1, 2
• Recurrent wheeze and persistent or recurrent cough, especially nocturnal 1, 2
• Nighttime disturbance by wheeze or cough 1, 2
• Symptoms triggered by viral infections, exercise, excitement, emotional disturbances, or allergens (cigarette smoke, pets, pollens, dust, feathers) 1, 2

Diagnosis in children under 2 years is particularly challenging and relies almost entirely on symptom patterns, with recurrent wheeze often associated with viral infections. 2

Goals of Management

The primary objectives prioritize morbidity and quality of life outcomes:

• Abolish symptoms completely 1
• Restore normal or best possible long-term airway function 1
• Reduce risk of severe attacks 1
• Enable normal growth 1
• Minimize school absences 1

Stepwise Pharmacologic Approach

Chronic Asthma Control (Steps 1-3)

Target outcomes include: 1

• Minimal chronic symptoms including nocturnal symptoms
• Minimal exacerbations
• Minimal need for rescue bronchodilators
• No activity limitations
• PEF ≥80% predicted or best with <20% circadian variation
• Minimal medication adverse effects

Inhaled corticosteroids (ICS) are the most potent long-term anti-inflammatory medications and form the foundation of controller therapy. 3 In UK primary care data, ICS monotherapy is prescribed for 90.6% of children initiating controller therapy. 4

Medication Delivery Systems

Most children cannot properly use unmodified metered-dose inhalers and require large volume spacer devices to enhance medication deposition. 2

Age-appropriate device selection: 2

• Ages 0-4 years: MDI with spacer and face mask
• Ages 5+ years: MDI with spacer or dry powder inhaler
• Nebulizers can be replaced by spacer devices in many cases 2

Before considering nebulized bronchodilators: 1

• Confirm diagnosis
• Explore other drug administration methods
• Ensure compliance with anti-inflammatory treatment
• Undertake 3-week home trial with peak flow monitoring

Rescue Therapy for Exacerbations

Short courses of oral corticosteroids (1-2 mg/kg body weight for 1-5 days) require no tapering in children. 1, 2

Indications for rescue steroids include: 1

• Progressive worsening symptoms and PEF day by day
• PEF falls below 60% of patient's best
• Sleep disturbed by asthma
• Morning symptoms persisting until midday
• Diminishing response to inhaled bronchodilators
• Emergency use of nebulized or injected bronchodilators

Acute Severe Asthma Recognition and Management

Recognition Criteria in Children

Acute severe asthma features: 1

• Too breathless to talk or feed
• Respirations >50 breaths/min
• Pulse >140 beats/min
• PEF <50% predicted or best

Life-threatening features: 1

• PEF <33% predicted or best
• Poor respiratory effort
• Cyanosis, silent chest, fatigue/exhaustion
• Agitation or reduced consciousness

Assessment in very young children may be difficult; presence of any severe features should alert the clinician. 1

Immediate Treatment Protocol

Step 1 - Initial therapy: 1, 5

• High-flow oxygen via face mask
• Intravenous hydrocortisone
• Salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses in very young children)
• Add ipratropium 100 mcg nebulized 6-hourly
• Repeat PEF measurement after starting treatment
• Maintain SaO2 >92% via oximetry

If life-threatening features present: 1

• Intravenous aminophylline 5 mg/kg over 20 minutes, followed by 1 mg/kg/h maintenance infusion
• Omit loading dose if child already receiving oral theophyllines

Step 2 - If improving: 1

• Continue high-flow oxygen
• Prednisolone 1-2 mg/kg daily (maximum 40 mg)
• Nebulized β-agonist 4-hourly

Step 3 - If not improving after 15-30 minutes: 1, 5

• Continue oxygen and steroids
• Increase nebulized β-agonist frequency to every 15-30 minutes
• Add ipratropium to nebulizer, repeat 6-hourly until improvement
• Consider continuous β-agonists, intravenous magnesium, helium-oxygen mixtures, intravenous terbutaline 5
• Consider non-invasive ventilation to limit work of breathing 5
• Low-dose ketamine infusions (with or without benzodiazepines) may improve tolerance of non-invasive ventilation 5

Step 4 - ICU transfer criteria: 1

• Deteriorating PEF or worsening exhaustion
• Feeble respirations
• Persistent hypoxia or hypercapnia
• Coma, respiratory arrest, confusion, or drowsiness

Environmental Control and Trigger Avoidance

General practitioners are best positioned to observe and modify environmental triggers, with maternal smoking being one of the most important. 1 Allergy identification should use specific IgE measurements and skin prick tests. 1 However, acaricides have shown little clinical benefit in studies. 1

Patient and Family Education

Management requires partnership between patient/family and healthcare professionals, with clear understanding that treatment will be prolonged. 1

Essential education components: 1, 2

• Written action plans provided to all families
• Proper inhaler technique instruction and verification
• Peak flow monitoring understanding for children ≥5 years
• When to vary medications according to symptoms or PEF
• When to call for help clearly defined
• Oral and written instructions on medication frequency and actions for worsening asthma

Supervision should involve attendance at asthma clinic or home visits by trained asthma nurse or physiotherapist. 1

Monitoring and Follow-up

Regular Assessment Parameters

Treatment outcome checklist: 1

• Days off school from asthma since last visit
• Amount of daytime and nighttime cough
• Frequency of relief medication use
• Activity limitations and wheeze
• Appropriateness of inhaler device for age and dosages
• Height and weight velocities documented 1

Growth monitoring is essential as asthma itself can delay growth and puberty, though catch-up growth typically occurs. 2 Inhaled corticosteroids may cause reduction in growth velocity, requiring close monitoring. 6

Discharge Criteria from Hospital

Children should have: 1

• Been on discharge medication for 24 hours
• Inhaler technique checked and recorded
• PEF >75% predicted or best (if recorded)
• PEF diurnal variability <25%
• Treatment with oral and inhaled steroids plus bronchodilators
• Own PEF meter and written self-management plan
• GP follow-up arranged within 1 week
• Respiratory clinic follow-up within 4 weeks

Important Caveats and Pitfalls

Antibiotics have no place in uncomplicated asthma management. 1 Antihistamines including ketotifen have proved disappointing in clinical practice. 1 Hyposensitization (immunotherapy) is not indicated in asthma management. 1

Always have a short-acting β2-agonist rescue inhaler available to treat sudden symptoms, as budesonide and other ICS do not treat acute wheezing. 6

Mouth rinsing with water after each ICS treatment reduces risk of oral thrush (candida). 6

Common pitfall: Parental expectations of asthma control are often lower than guideline targets, which may contribute to undertreatment, particularly in younger age groups. 7 Even with poor control, 89% of parents report satisfaction with treatment. 7

Adrenal insufficiency warning: Children transferring from systemic corticosteroids should taper slowly and carry a warning card stating they may need corticosteroids during stress or severe attacks. 6