Initial Management of Pediatric Asthma
For children with persistent asthma (symptoms >2 days/week or >2 nights/month), initiate low-dose inhaled corticosteroids as first-line controller therapy, delivered via age-appropriate device with proper technique verification. 1
Defining Persistent Asthma Requiring Treatment
Treatment should be initiated when children meet criteria for persistent disease:
- More than 3 episodes of wheezing in the past year lasting more than 1 day and affecting sleep 1
- Risk factors warranting treatment include parental history of asthma or physician-diagnosed atopic dermatitis, OR two or more of: physician-diagnosed allergic rhinitis, peripheral blood eosinophilia, or wheezing apart from colds 1
- Impairment symptoms present >2 days/week or >2 nights/month characterize persistent disease requiring daily controller therapy 2
Age-Specific Treatment Algorithm
Children Under 5 Years
Primary therapy: Low-dose inhaled corticosteroids via nebulizer, dry powder inhaler (DPI), or metered-dose inhaler (MDI) with holding chamber/face mask 1
Alternative options (when ICS cannot be used or for milder cases):
Children 5-11 Years
Primary therapy: Low-dose inhaled corticosteroids 1
Alternative therapies include:
- Leukotriene receptor antagonists (montelukast) 1
- Cromolyn or nedocromil 1
- Sustained-release theophylline 1
Children 12 Years and Older
Primary options:
- Daily low-dose ICS with as-needed short-acting beta-agonist (SABA) 1
- As-needed ICS and SABA used concomitantly 1
For moderate to severe persistent asthma: ICS-formoterol in a single inhaler as both daily controller and reliever therapy 1
Inhaled Corticosteroid Safety Profile
The evidence strongly supports ICS safety in children:
- Long-term studies (up to 6 years) demonstrate that recommended doses of ICS do not cause clinically significant or irreversible effects on vertical growth, bone mineral density, ocular toxicity, or adrenal/pituitary axis suppression 1
- Most children treated with ICS achieve their predicted adult heights based on available long-term data 3
- The potential albeit small risk of delayed growth is well balanced by effectiveness in improving health outcomes for children with mild or moderate persistent asthma 3
Monitoring and Adjustment Strategy
Initial assessment timeline:
- Assess response to therapy within 4-6 weeks 1
- Consider alternative therapies or diagnoses if clear benefit is not observed within this timeframe 1
Step-down approach:
- Once control is established and sustained, attempt careful step-down in therapy 1
- Titrate to the lowest effective dose to maintain control while minimizing potential side effects 1
Step-Up Therapy for Inadequate Control
For children under 4 years with inadequate control on low-dose ICS:
Preferred options:
- Add long-acting inhaled beta2-agonists to low-dose ICS 1
- Increase ICS dose to medium-dose range (most effective in reducing exacerbations) 1
Alternative options:
- Add LTRA or theophylline (with serum concentration monitoring) to low-to-medium dose ICS 1
For children 4 years and older:
Special Clinical Scenarios
Exercise-induced symptoms:
Allergic asthma (≥5 years with controlled symptoms):
- Subcutaneous immunotherapy (SCIT) may be considered as adjunct treatment 1
Critical Pitfalls to Avoid
Diagnostic confusion: Not all wheezing in young children is asthma; viral respiratory infections are the most common cause of wheezing in preschool-aged children 1
Undertreatment: Underdiagnosis and undertreatment are key problems in young children with asthma, and early recognition with appropriate treatment of high-risk children may result in secondary prevention and improved long-term outcomes 1
Device and technique errors: Inhaler technique must be checked and recorded before discharge or at follow-up visits 3
Premature discontinuation: Children should be on discharge medication for 24 hours with verified inhaler technique before discontinuing acute treatment 3