At what age can albuterol (bronchodilator) breathing treatment be started?

Albuterol Breathing Treatment Age Guidelines

Albuterol nebulizer solution can be started at 2 years of age, as this is the FDA-approved minimum age for albuterol inhalation solution. 1

FDA-Approved Age Indications

• Nebulizer solution: FDA-approved for children ≥2 years of age for relief of bronchospasm in reversible obstructive airway disease and acute bronchospasm attacks 1
• Metered-dose inhaler (MDI): Can be used in children <5 years of age when delivered via spacer/valved holding chamber with face mask 2
• Levalbuterol HFA: Not approved for children <4 years of age 2

Delivery Method Considerations by Age

Children Under 4 Years

• Nebulizer with face mask is the preferred delivery method, as many children cannot cooperate adequately with MDIs or dry powder inhalers (DPIs) 2
• Parents must assist with MDI plus valved holding chamber or nebulizer administration 2
• Face mask use combined with low tidal volumes results in lower aerosol delivery in younger infants 2

Children 4-5 Years

• Most can generate sufficient peak inspiratory flows for adequate DPI dosing 2
• MDI with spacer/valved holding chamber remains effective 2
• Children <4 years may not generate sufficient inspiratory flow to activate an autohaler 2

Children ≥5 Years

• Can reliably perform spirometry for objective assessment 2
• Multiple delivery systems become appropriate (MDI, DPI, nebulizer) 2

Clinical Evidence in Young Children

Research supports albuterol use even below the FDA-approved age in specific clinical contexts:

• A safety trial demonstrated that albuterol HFA 180-360 mcg via MDI-spacer with face mask in children <2 years with acute wheezing improved symptoms by 48% without significant safety issues 3
• Nebulized albuterol (0.15 mg/kg/dose) in infants 6 weeks to 24 months with bronchiolitis showed significant improvement in accessory muscle use, respiratory rate, and oxygen saturation 4
• Impulse oscillometry studies confirmed bronchodilator response to albuterol in children 2-5 years with asthma 5

National Asthma Guidelines Framework

The NAEPP Expert Panel Report 3 designates albuterol as:

• The drug of choice for acute bronchospasm across all age groups 2
• A short-acting beta-agonist (SABA) that relaxes smooth muscle and provides relief of acute symptoms 2
• Not recommended for long-term daily treatment; regular use exceeding 2 days/week for symptom control indicates poor asthma control 2

Dosing by Age

Children <5 Years (Nebulizer)

• 0.63 mg/3 mL for routine use 2
• 1.25-2.5 mg in 3 mL saline for acute exacerbations 2
• May double dose for severe exacerbations 2

Children 5-11 Years (Nebulizer)

• 1.25-5 mg in 3 mL saline 2

MDI Dosing (All Ages When Appropriate)

• 1-2 puffs (200 mcg/puff) every 4-6 hours as needed 2
• May double usual dose for mild exacerbations 2

Important Safety Considerations

Common adverse effects include:

• Tachycardia, skeletal muscle tremor, hypokalemia, headache, hyperglycemia 2
• Inhaled route generally causes few systemic adverse effects 2
• No serious adverse events reported in pediatric safety studies 3

Critical caveat: Increasing albuterol use or lack of expected effect indicates diminished asthma control and requires reassessment of controller therapy 2

Special Populations

Preterm infants with post-prematurity respiratory disease (PPRD):

• May benefit from trial of bronchodilator therapy for recurrent respiratory symptoms 2
• Response rates vary: 35% of infants with BPD respond to albuterol, with 55% response in those with recurrent wheeze versus only 12.5% without wheezing 2
• These children may have fixed airway obstruction or tracheomalacia and be less responsive than children with typical asthma 2