Pediatric Asthma Treatment
Inhaled corticosteroids (ICS) are the first-line controller therapy for all children with persistent asthma, with age-specific delivery methods and dosing strategies that prioritize low-dose ICS to minimize side effects while maintaining control. 1, 2, 3
Treatment Algorithm by Age Group
Children Under 5 Years
Low-dose inhaled corticosteroids via nebulizer, dry powder inhaler (DPI), or metered-dose inhaler (MDI) with holding chamber/face mask represent first-line therapy. 1, 3
Budesonide nebulizer solution is FDA-approved for children 1-8 years of age and represents the preferred inhaled corticosteroid option for this age group. 3, 4
Use a nebulizer or MDI with valved holding chamber (spacer) and face mask for children under 4 years of age, as they cannot coordinate standard MDI technique. 3
Alternative therapies include leukotriene receptor antagonists (LTRAs) such as montelukast, which is FDA-approved down to 1 year of age in granule formulation, particularly when inhaled medication delivery is suboptimal due to poor technique or adherence. 1, 3, 5
Cromolyn sodium is another alternative, though less preferred than ICS. 1, 3
Do not use long-acting beta-agonists (LABA) or ICS-formoterol as single maintenance and reliever therapy (SMART) in children under 5 years, as no evidence supports safety or efficacy in this age group. 2
Children 5-11 Years
Low-dose inhaled corticosteroids remain first-line therapy. 1
Alternative therapies include LTRAs (montelukast), cromolyn or nedocromil, and sustained-release theophylline. 1
For moderate to severe persistent asthma (Steps 3 and 4), ICS-formoterol as single maintenance and reliever therapy (SMART) is recommended with age-appropriate ICS dosing, though this represents a conditional recommendation with moderate certainty of evidence. 2
Note that Global Initiative for Asthma guidelines do not endorse SMART for children aged 5-11 years, differing from National Asthma Education and Prevention Program guidelines. 2
Children 12 Years and Older (Adolescents)
Daily low-dose ICS with as-needed short-acting beta-agonist (SABA), or as-needed ICS and SABA used concomitantly represent first-line options. 1
For moderate to severe persistent asthma, ICS-formoterol in a single inhaler as both daily controller and reliever therapy is strongly recommended, with high certainty of evidence. 1, 2
Step-Up Therapy for Inadequate Control
For Children Under 4 Years
Two preferred options exist: (1) adding long-acting inhaled beta2-agonists to low-dose ICS (extrapolated from adult studies), or (2) increasing the dose of ICS within the medium-dose range. 6
However, there are no data on long-acting beta2-agonists in children under 4 years of age, and medium doses of ICS have been shown effective in treating moderate and severe asthma in infants and young children. 6
Medium doses of ICS as monotherapy for moderate asthma represent a preferred treatment option in this age group, as increasing the dose is most effective in reducing asthma exacerbations. 6
Alternative but not preferred options include adding either LTRA or theophylline (if serum concentrations are monitored) to low-to-medium doses of ICS. 6
For Children 4 Years and Older
Step-up options include increasing ICS dose, adding LABA, or adding LTRA. 1
Inhaled corticosteroids are superior to montelukast at modifying exacerbation risk. 7
Monitoring and Response Assessment
Assess response to therapy within 4-6 weeks of initiation: if no clear benefit is observed and technique/adherence are adequate, discontinue therapy and consider alternative diagnoses. 1, 2, 3
Monitor for signs of asthma control at each visit, and track total daily inhaler use to indicate poor control. 2
Once control is established and sustained for at least 3 months, attempt a careful step-down in therapy. 1, 2
Monitor growth in pediatric patients on long-term ICS therapy, as dose-related growth suppression can occur, though this effect is small and non-progressive. 2, 3
Safety Considerations
Strong evidence from clinical trials following children for up to 6 years suggests that the use of inhaled corticosteroids at recommended doses does not have long-term, clinically significant, or irreversible effects on vertical growth, bone mineral density, ocular toxicity, or suppression of adrenal/pituitary axis. 6
Titrate to the lowest effective dose to maintain control while minimizing potential side effects, as adverse events are associated with high doses of ICS. 1, 8
Intermittent ICS (budesonide and beclomethasone) were associated with greater growth by 0.41 cm compared to daily treatment, though daily ICS was superior in lung function, airway inflammation, asthma control and reliever use. 9
Common Pitfalls and Caveats
Not all wheezing in young children is asthma; viral respiratory infections are the most common cause of wheezing in preschool-aged children, and diagnostic uncertainty is common in children 0-3 years old. 1, 3
Children with a history of an asthma exacerbation requiring a systemic corticosteroid in the past year are more than twice as likely to have a subsequent exacerbation despite controller treatment. 7
Underdiagnosis and undertreatment are key problems in young children with asthma, and early recognition and appropriate treatment of high-risk children may result in secondary prevention of childhood asthma and improved long-term outcomes. 1
Poor patient compliance is a major barrier to treatment; simplified dosing regimens (e.g., once-daily administration), good inhaler technique, and education of the patient/caregiver should improve patient compliance. 8
Do not increase ICS dose during exacerbations in adherent patients. 2