Initial Treatment for Pediatric Asthma

Low-dose inhaled corticosteroids (ICS) are the first-line controller therapy for all children with persistent asthma, regardless of age. 1

Age-Specific Treatment Recommendations

Initiate low-dose ICS via nebulizer, dry powder inhaler (DPI), or metered-dose inhaler (MDI) with holding chamber/face mask as first-line therapy for children with persistent symptoms (>3 episodes of wheezing in the past year lasting >1 day and affecting sleep). 1
Alternative options include leukotriene receptor antagonists (LTRAs) such as montelukast or cromolyn sodium, though these are less effective than ICS. 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

Start with low-dose ICS as first-line therapy, delivered via age-appropriate device. 1
Alternative therapies (when ICS cannot be used) include LTRAs (montelukast), cromolyn or nedocromil, and sustained-release theophylline. 1
Assess response within 4-6 weeks; if no clear benefit is observed, consider alternative diagnoses or therapies. 1

Two first-line options exist: (1) daily low-dose ICS with as-needed short-acting beta-agonist (SABA), or (2) 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 is recommended. 1, 2

Use spacers or valved holding chambers (VHCs) with MDIs to reduce local side effects and improve drug delivery. 3
For children under 5 years, use face masks with spacers to ensure adequate delivery. 1
Instruct patients to rinse mouth (rinse and spit) after ICS inhalation to minimize local adverse effects. 3

Start with low-dose ICS (fluticasone propionate 100 mcg twice daily or equivalent) as most benefits occur in the low-to-medium dose range. 3, 4
Low-dose fluticasone propionate (100-200 mcg/day) does not cause growth suppression in children with mild asthma. 4
Titrate to the lowest effective dose that maintains control to minimize potential side effects. 3, 1

Evaluate response to therapy within 4-6 weeks of initiation, assessing symptom control, exacerbation frequency, and adherence. 1, 2
If no clear benefit is observed within this timeframe, stop treatment and consider alternative diagnoses or therapies. 1
Once control is established and sustained for at least 3 months, attempt careful step-down in therapy. 1, 2

Do not delay ICS initiation in children with persistent symptoms, as underdiagnosis and undertreatment are key problems in pediatric asthma. 1
Not all wheezing in young children is asthma—viral respiratory infections are the most common cause of wheezing in preschool-aged children, so confirm diagnosis before long-term treatment. 1
Avoid using LABA monotherapy (without ICS) in any pediatric age group, as this increases mortality risk. 3
Do not use immunotherapy (hyposensitization) as initial management, as it is not indicated in asthma management. 3
Antibiotics have no place in uncomplicated asthma management. 3

Address maternal smoking and other environmental triggers, as general practitioners are in the best position to observe and modify these factors. 3
Identify specific allergen triggers through IgE measurements and skin prick tests when appropriate. 3

Monitor growth velocity in all children on long-term ICS therapy, documenting height and weight at each visit. 3, 2
Strong evidence suggests that ICS at recommended doses does not have long-term, clinically significant effects on growth, bone mineral density, or HPA axis suppression when followed for up to 6 years. 1
Any small effect on growth velocity (approximately 1 cm) appears to occur in the first several months of treatment and is not progressive. 3