What are the latest guidelines for managing asthma in pediatric patients?

Latest Guidelines for Pediatric Asthma Management

Inhaled corticosteroids (ICS) are the preferred first-line controller therapy for children with persistent asthma, with low-dose ICS recommended for children ≥5 years with mild persistent asthma and combination ICS/LABA reserved for those inadequately controlled on ICS monotherapy. 1

Controller Medication Selection by Age and Severity

Children ≥5 Years with Mild Persistent Asthma

• Preferred therapy: Low-dose inhaled corticosteroids (fluticasone 100 mcg, budesonide equivalent) 1
• Alternative therapies include (listed alphabetically as evidence is insufficient for ranking):
  • Cromolyn 1
  • Leukotriene receptor antagonists (LTRAs) 1
  • Nedocromil 1
  • Sustained-release theophylline 1

Children <5 Years with Mild Persistent Asthma

• Preferred therapy: Low-dose inhaled corticosteroids via nebulizer, dry powder inhaler, or metered-dose inhaler with holding chamber (with or without face mask) 1
• Alternative therapies: Cromolyn or LTRA 1
• Important caveat: No direct comparative studies exist in this age group; recommendations are extrapolated from older children 1

Moderate to Severe Persistent Asthma (Ages 4-11 Years)

• For children not controlled on ICS alone: Fluticasone/salmeterol 100/50 mcg twice daily 2
• Maximum recommended dose: Fluticasone/salmeterol 500/50 mcg twice daily in adolescents ≥12 years 2

Adolescents ≥12 Years

• Dosing options: Fluticasone/salmeterol 100/50,250/50, or 500/50 mcg twice daily based on disease severity 2
• Starting strength should be based on previous ICS dose, asthma control, and exacerbation risk 2

Acute Asthma Exacerbations

Recognition of Acute Severe Asthma in Children

Life-threatening features include: 1

• Too breathless to talk or feed
• Respiratory rate >50 breaths/min
• Pulse >140 beats/min
• Peak expiratory flow (PEF) <50% predicted
• PEF <33% predicted, cyanosis, silent chest, fatigue, or altered consciousness

Immediate Treatment Protocol

First-line therapy consists of three simultaneous interventions: 3, 4

1. High-flow oxygen via face mask (maintain SaO₂ >92%) 3, 4
2. Nebulized salbutamol:
   • 5 mg for children >20 kg 3
   • 2.5 mg for children <20 kg 3
   • Half doses in very young children 1
3. Intravenous hydrocortisone immediately 1, 4

Additional Acute Management

• Add ipratropium 100 mcg nebulized every 6 hours for moderate to severe exacerbations 1, 3
• If life-threatening features present: IV aminophylline 5 mg/kg over 20 minutes, then 1 mg/kg/h maintenance (omit loading dose if already on oral theophyllines) 1
• Repeat PEF measurement 15-30 minutes after starting treatment (if age-appropriate) 4

If Not Improving After 15-30 Minutes

• Continue oxygen and steroids 1
• Increase nebulized β-agonist frequency to every 30 minutes 1
• Continue ipratropium every 6 hours 1

Transition to Oral Therapy

• Switch to oral prednisolone 1-2 mg/kg daily (maximum 40 mg) once improving 1, 4

Discharge Criteria and Follow-Up

Children may be discharged when: 1, 4

• On discharge medications for 24 hours with verified inhaler technique
• PEF >75% of predicted or best (if measurable)
• PEF diurnal variability <25%
• Prescribed oral steroids, inhaled steroids, and bronchodilators
• Own peak flow meter with written self-management plan (age-appropriate)
• GP follow-up scheduled within 1 week
• Respiratory clinic follow-up within 4 weeks

Critical Safety Considerations

Growth Monitoring with ICS

• A dose-dependent effect on linear growth velocity exists: High-quality evidence shows children on low-to-medium dose ICS (200 mcg HFA-beclomethasone equivalent) grow 0.20 cm/year slower than those on low-dose ICS (50-100 mcg) 5
• Use the lowest effective ICS dose to minimize growth suppression 5
• Short-term reductions in tibial growth rate occur at doses >400 mcg/day, though long-term implications remain unclear 1
• Monitor height regularly in all children on ICS 2

LABA Safety

• Never use LABA as monotherapy - associated with increased asthma-related death and hospitalization 2
• Do not combine ICS/LABA with additional LABA from any source (risk of overdose) 2
• When used in fixed-dose combination with ICS, large trials show no significant increase in serious asthma-related events compared to ICS alone 2

Common Pitfalls to Avoid

• Do not delay corticosteroids in acute exacerbations - they must be given concurrently with bronchodilators 3, 4
• Avoid overreliance on short-acting β-agonists without adequate controller medications 3
• Always verify inhaler technique - inadequate technique leads to suboptimal delivery 3, 4
• Do not use lidocaine (IV or topical) at induction in children with respiratory symptoms - not recommended 3
• Rinse mouth with water after ICS use without swallowing to reduce oropharyngeal candidiasis risk 2

Self-Management Education

Essential components for all families: 1

• Training in proper inhaler technique and peak flow meter use (age-appropriate)
• Understanding difference between "relievers" (bronchodilators) and "preventers" (ICS)
• Recognition of worsening asthma signs, especially nocturnal symptoms
• Written action plan with three elements:
  1. Monitoring symptoms, peak flow, and medication use
  2. Prearranged patient-initiated actions
  3. Written guidance on when to increase ICS, start oral steroids (PEF <60% predicted), or seek urgent care