What is the recommended daily inhaler treatment for children with mild to moderate asthma?

Daily Inhaler for Children with Asthma

Low-dose inhaled corticosteroids (ICS) are the recommended first-line daily controller therapy for children with mild to moderate persistent asthma across all pediatric age groups. 1, 2, 3

Treatment Algorithm by Age

Children Under 5 Years

• Start with low-dose ICS via nebulizer, dry powder inhaler (DPI), or metered-dose inhaler (MDI) with holding chamber/face mask as first-line therapy 1, 2
• Budesonide nebulizer solution is FDA-approved from age 1 year and is the preferred formulation for children under 4 years who cannot effectively use other devices 2
• Fluticasone DPI is FDA-approved for children 4 years and older 2, 4
• Delivery technique matters: use a face mask that fits snugly over nose and mouth, and wash the face after each treatment to prevent local side effects 3

Alternative option: Montelukast 4 mg chewable tablet (FDA-approved for ages 2-6 years) can be used when inhaled medication delivery is suboptimal due to poor technique or adherence issues, though it is less effective than ICS 2, 3

Children 5-11 Years

• Low-dose ICS remains first-line therapy 1
• Alternative therapies include leukotriene receptor antagonists (montelukast), cromolyn, nedocromil, or sustained-release theophylline 1
• The PACT trial definitively demonstrated that fluticasone monotherapy gained an average of 42 additional asthma control days per year compared to montelukast (p=0.004), with a number needed to treat of approximately 6.5 5

Children 12 Years and Older

• Daily low-dose ICS with as-needed short-acting beta-agonist (SABA) is the primary first-line option 1
• For moderate to severe persistent asthma, ICS-formoterol in a single inhaler as both daily controller and reliever therapy is recommended 1

When to Initiate Daily Controller Therapy

Start daily controller medication when children have: 3

• Symptomatic treatment needed more than 2 times per week
• Severe exacerbations requiring beta-agonist more frequently than every 4 hours over 24 hours
• More than 3 episodes of wheezing in the past year lasting more than 1 day and affecting sleep 1

Risk factors that should prompt treatment include parental history of asthma, physician-diagnosed atopic dermatitis, allergic rhinitis, peripheral blood eosinophilia, or wheezing apart from colds 1

Step-Up Therapy for Inadequate Control

For Children Under 4 Years

Two preferred options exist: 1

1. Add long-acting inhaled beta2-agonists (LABA) to low-dose ICS
2. Increase the dose of ICS to medium-dose range (most effective in reducing asthma exacerbations)

For Children 5-11 Years

According to NAEPP guidelines: 5

• Step 3: Low-dose ICS plus LABA, OR medium-dose ICS alone
• Alternative: Low-dose ICS plus leukotriene receptor antagonist
• Step 4: Medium-dose ICS plus LABA

For Children 12 Years and Older

• Follow the same stepwise approach as adults, with medium-dose ICS plus LABA as the preferred option for step 4 5

Critical Safety Considerations

ICS Safety Profile:

• Strong evidence from clinical trials following children for up to 6 years shows that ICS at recommended doses does not have long-term, clinically significant, or irreversible effects on vertical growth, bone mineral density, ocular toxicity, or suppression of adrenal/pituitary axis 1
• The benefits of ICS clearly outweigh concerns about potential adverse effects, including the small, nonprogressive reduction in growth velocity 2
• Titrate to the lowest effective dose needed to maintain control 2, 3
• Monitor linear growth in young children, as individual susceptibility to growth suppression varies considerably 3
• Advise mouth rinsing after each treatment to reduce risk of oral candidiasis 5, 2

LABA Safety:

• Never use LABAs as monotherapy—they should only be used in combination with ICS 5, 2, 4
• Available data strongly suggest that long-acting beta agonists should never be used as monotherapy for long-term control of persistent asthma due to increased risk of severe exacerbations and deaths 5
• LABAs are FDA-approved only for children 4 years and older 2, 4

Monitoring and Follow-Up

• Assess response to therapy within 4-6 weeks 1, 2, 3
• Stop treatment if no clear beneficial effect is obvious within 4-6 weeks and consider alternative therapies or diagnoses 1, 3
• Once asthma control is sustained for 2-4 months, step down therapy to the minimum dose required to maintain control 1, 3

Common Pitfalls to Avoid

• Do not overtreat viral-induced wheeze that resolves between episodes—not all wheezing in young children is asthma, as viral respiratory infections are the most common cause of wheezing in preschool-aged children 1, 2
• Do not start with high-dose ICS; begin with low doses and titrate up only if needed 2
• Do not prescribe LABAs as monotherapy 2
• Ensure proper inhaler technique, as poor technique is a major cause of treatment failure 2
• Do not use theophylline as an alternative controller in young children with mild persistent asthma due to risks of adverse effects 3
• Underdiagnosis and undertreatment are key problems in young children with asthma—early recognition and appropriate treatment of high-risk children may result in secondary prevention of childhood asthma and improved long-term outcomes 1