What is the treatment for pediatric asthma?

Treatment for Pediatric Asthma

Low-dose inhaled corticosteroids (ICS) are the first-line treatment for persistent asthma in children of all ages, delivered via nebulizer, metered-dose inhaler with spacer, or dry powder inhaler depending on age and ability. 1, 2

Initial Assessment: Who Needs Treatment?

Start long-term controller therapy when children meet these criteria:

• More than 3 wheezing episodes in the past year lasting >1 day and affecting sleep 1
• Symptoms requiring treatment >2 times per week or severe exacerbations needing beta-agonist more frequently than every 4 hours over 24 hours 2
• Risk factors present: parental asthma history or physician-diagnosed atopic dermatitis, OR two or more of: allergic rhinitis, peripheral eosinophilia, wheezing apart from colds 1

Treatment Algorithm by Age

Children Under 5 Years

First-line therapy:

• Budesonide nebulizer solution (FDA-approved from age 1 year) is the preferred formulation for children under 4 years who cannot effectively use other devices 2
• Fluticasone dry powder inhaler (FDA-approved from age 4 years) 2
• Deliver via nebulizer or MDI with valved holding chamber (spacer), with or without face mask for children under 4 years 2

Alternative therapy (when ICS delivery is suboptimal):

• Montelukast 4 mg chewable tablet (FDA-approved for ages 2-6 years) 2, 3
• Consider when inhaler technique or adherence is poor 2
• Evidence for efficacy is less robust than ICS 2

Critical pitfall: Do not overtreat viral-induced wheeze that resolves completely between episodes—not all wheezing in young children is asthma 2

Children 5-11 Years

First-line therapy:

• Low-dose ICS via MDI with spacer or DPI 1

Alternative therapies:

• Montelukast (leukotriene receptor antagonist) 1
• Cromolyn or nedocromil 1
• Sustained-release theophylline 1

Children 12 Years and Older

First-line 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

Step-Up Therapy for Inadequate Control

Children Under 4 Years

When low-dose ICS fails, two preferred options exist:

• Add long-acting beta-agonist (LABA) to low-dose ICS 1
• Increase ICS to medium-dose range—this is most effective in reducing exacerbations in this age group 1

Alternative (not preferred): Add LTRA or theophylline (with serum monitoring) to low-to-medium dose ICS 1

Children 4 Years and Older

Step-up options include:

• Increase ICS dose 1
• Add LABA (FDA-approved from age 4 years) 2
• Add LTRA 1

Critical warning: LABAs should NEVER be used as monotherapy—only in combination with ICS 2

Delivery Device Selection

Age-appropriate delivery is essential for efficacy:

• Under 4 years: Nebulizer or MDI with valved holding chamber and face mask 2
• 4 years and older: DPI or MDI with spacer (no face mask needed) 2
• All ages: Ensure proper inhaler technique at every visit 2

Safety Profile of ICS

ICS benefits clearly outweigh risks, even in young children:

• Strong evidence from trials following children up to 6 years shows no long-term, clinically significant, or irreversible effects on growth, bone mineral density, ocular toxicity, or adrenal/pituitary suppression at recommended doses 1
• Low-to-medium dose ICS have no clinically significant effects on HPA axis function in most children 4
• Small, nonprogressive reduction in growth velocity is not clinically significant 2

Minimize potential side effects:

• Titrate to the lowest effective dose to maintain control 1, 2
• Mouth rinsing after each treatment reduces local side effects 2, 4
• Start with low doses and titrate up only if needed—do not use high-dose ICS initially 2

Monitoring and Adjustment

Assess response within 4-6 weeks:

• If no clear benefit is observed, consider alternative therapies or diagnoses 1, 2
• Once control is established and sustained, attempt careful step-down in therapy 1

For children on concomitant ICS with frequent exacerbations:

• Step-up options include increasing ICS dose, adding LABA (age 4+), or adding LTRA 1
• Montelukast added to beclomethasone resulted in statistically significant improvements in FEV1 compared to beclomethasone alone 3

Special Populations

Exercise-induced symptoms:

• Add pre-exercise dose of SABA or use ICS-LABA combination therapy 1

Allergic asthma (age 5+ with controlled symptoms):

• Subcutaneous immunotherapy (SCIT) may be considered as adjunct treatment 1

When to Consider Montelukast Over ICS

Despite ICS being preferred first-line therapy, montelukast may be more appropriate in specific scenarios:

• Poor inhaler technique or adherence issues that cannot be resolved 2
• Viral-induced wheezing pattern (theoretical and clinical trial evidence shows LTRAs more effective than ICS for this phenotype) 5
• Inability to use ICS or concerns about growth in children with poor growth 6

However: If montelukast is selected and asthma is not adequately controlled within 4-6 weeks, discontinue and initiate ICS 2, 7

Evidence shows: Low-dose fluticasone is more effective than montelukast for mild to moderate persistent asthma, with weighted mean difference of 4.6% predicted FEV1 and 5.6% more asthma control days 7

Common Pitfalls to Avoid

• Underdiagnosis and undertreatment in young children—early recognition and appropriate treatment may result in secondary prevention and improved long-term outcomes 1
• Using LABAs as monotherapy—always combine with ICS 2
• Starting with high-dose ICS—begin low and titrate up only if needed 2
• Ignoring inhaler technique—verify at every visit 2
• Not attempting step-down therapy once control is sustained 1