What is the first line treatment for asthma in children?

First-Line Treatment for Asthma in Children

Low-dose inhaled corticosteroids (ICS) are the preferred first-line treatment for children with persistent asthma, regardless of age. This recommendation is supported by strong evidence showing superior outcomes compared to all alternative therapies, including leukotriene receptor antagonists, cromolyn, nedocromil, and theophylline 1, 2, 3.

Treatment by Age Group

Children 5 Years and Older

• Start with low-dose inhaled corticosteroids delivered via metered-dose inhaler with spacer or dry powder inhaler 1, 2, 3
• ICS demonstrate superior efficacy in improving lung function (FEV1), reducing airway hyperresponsiveness, decreasing symptom scores, reducing oral corticosteroid courses, and preventing urgent care visits or hospitalizations 1, 3
• Alternative therapies (cromolyn, leukotriene receptor antagonists like montelukast, nedocromil, or sustained-release theophylline) are less effective and should only be considered if ICS cannot be used 1, 2

Children Under 5 Years

• Low-dose inhaled corticosteroids remain the preferred therapy, delivered via nebulizer, dry powder inhaler, or metered-dose inhaler with holding chamber (with or without face mask) 1, 2, 3
• Budesonide nebulizer solution is FDA-approved for children as young as 1 year with persistent asthma 3, 4
• Alternative options include leukotriene receptor antagonists (montelukast 4 mg chewable tablet for ages 2-5 years) or cromolyn, though these are less effective 1, 2, 5
• Avoid theophylline in young children with mild persistent asthma due to risk of adverse effects, particularly during febrile illnesses which increase theophylline concentrations 1, 2

Evidence Supporting ICS Superiority

The Pediatric Asthma Controller Trial (PACT) provides definitive evidence for ICS as first-line therapy 1:

• Fluticasone propionate (FP) monotherapy gained an average of 42 additional asthma control days per year compared to montelukast (p=0.004) 1
• The number needed to treat (NNT) is approximately 6.5, meaning 7 children need treatment with ICS instead of montelukast to achieve one additional treatment response 1
• ICS demonstrated superior outcomes across all measures: asthma control days, Asthma Control Questionnaire scores, albuterol use, lung function parameters (FEV1/FVC), peak flow variability, and inflammatory biomarkers (exhaled nitric oxide) 1

When to Consider Alternative First-Line Therapy

Leukotriene receptor antagonists may be considered as initial therapy only when:

• Inhaler technique is suboptimal and cannot be corrected despite education 1, 2
• Adherence to inhaled medications is consistently poor 1, 2
• Parents refuse ICS therapy despite counseling 2

However, even in these situations, efforts should focus on addressing barriers to ICS use rather than accepting less effective therapy 2.

Monitoring and Adjustment

• Assess response within 4-6 weeks: If no clear benefit is observed, consider alternative diagnoses or therapies 1, 2, 3
• Step down therapy after 2-4 months of sustained control to find the minimum effective dose 1, 2, 3
• Monitor growth in all children on ICS, though clinically significant growth suppression is rare at recommended low-to-medium doses 1, 5, 6
• Ensure proper inhaler technique at every visit, as poor technique is a major cause of treatment failure 7

Common Pitfalls to Avoid

Undertreatment is the most critical error in pediatric asthma management 2, 5:

• Starting with less effective alternatives (like montelukast) delays optimal control and may lead to permanent airway changes 2
• Inadequate dosing of ICS due to excessive fear of side effects results in poor asthma control 6
• Failing to recognize that growth concerns with ICS at recommended doses are minimal and far outweighed by benefits of asthma control 1, 5, 6

Do not delay ICS therapy in children with:

• More than 2 daytime symptoms per week 2
• Any nighttime awakenings due to asthma 2
• Any activity limitation from asthma 2
• More than 2 uses of rescue inhaler per week (excluding pre-exercise use) 2

Step-Up Therapy for Inadequate Control

If asthma remains uncontrolled on low-dose ICS after 4-6 weeks with confirmed good adherence and technique 2:

• For children 4 years and older: Add long-acting beta2-agonist (LABA) to low-dose ICS OR increase to medium-dose ICS 1, 5, 4
• For children under 4 years: Increase to medium-dose ICS as the preferred option, as this is most effective in reducing exacerbations in this age group 5
• Less preferred alternatives include adding leukotriene receptor antagonist or theophylline (with serum monitoring) to low-dose ICS 1, 5