What are the treatment recommendations for asthma in children under 12 according to the Global Initiative for Asthma (GINA) guidelines?

GINA Asthma Guidelines for Children Under 12 Years

Age-Specific Treatment Recommendations

Children Under 5 Years (0-4 years)

Low-dose inhaled corticosteroids (ICS) delivered via nebulizer, dry powder inhaler, or metered-dose inhaler with holding chamber (with or without face mask) are the preferred first-line controller therapy for persistent asthma in this age group. 1, 2, 3

• Budesonide nebulizer solution is FDA-approved starting at age 1 year and represents the preferred formulation for children under 4 years who cannot effectively use other devices 3, 4
• ICS are the most effective anti-inflammatory treatment available and should be the initial controller medication for persistent asthma 3, 5
• Initiate daily long-term controller therapy when symptoms require treatment more than 2 times per week, or when severe exacerbations require beta-agonist more frequently than every 4 hours over 24 hours 3

Alternative (not preferred) options include:

• Leukotriene receptor antagonists (LTRAs) such as montelukast 4 mg chewable tablet (FDA-approved for ages 2-6 years) 1, 2, 4
• Cromolyn sodium 1, 2
• Consider LTRAs when inhaled medication delivery is suboptimal due to poor technique or adherence issues 3

Critical implementation points:

• Assess response within 4-6 weeks of initiating therapy, and stop treatment if no clear beneficial effect is observed within this timeframe 3
• Titrate ICS to the lowest effective dose needed to maintain asthma control to minimize potential adverse effects 3, 6
• Mouth rinsing after each treatment reduces local side effects 3

Common pitfalls to avoid:

• Do not overtreat viral-induced wheeze that resolves between episodes 3
• Do not use high-dose ICS initially; start with low doses and titrate up only if needed 3
• Not all wheezing in young children is asthma; viral respiratory infections are the most common cause of wheezing in preschool-aged children 2

Children 5-11 Years

Low-dose inhaled corticosteroids remain the preferred first-line therapy for mild persistent asthma in this age group. 1, 2

• Fluticasone dry powder inhaler is FDA-approved for children 4 years and older 3
• The 5-mg chewable tablet of montelukast should be used in pediatric patients 6 to 14 years of age as an alternative option 4

Alternative therapies include:

• Leukotriene receptor antagonists (montelukast) 1, 2
• Cromolyn or nedocromil 1
• Sustained-release theophylline 1

Step-up therapy for inadequate control:

• Two preferred options exist: (1) adding long-acting inhaled beta2-agonists (LABA) to low-dose ICS, or (2) increasing the dose of ICS within the medium-dose range 1
• Salmeterol DPI is FDA-approved only for children 4 years and older, and LABAs should never be used as monotherapy 3, 7
• Alternative but not preferred options include adding either LTRA or theophylline (if serum concentrations are monitored) to low-to-medium doses of ICS 1

Special considerations:

• For children with allergic asthma aged 5 years and older with controlled symptoms, subcutaneous immunotherapy (SCIT) may be considered as an adjunct treatment 8, 1
• For children with exercise-induced symptoms, adding a pre-exercise dose of SABA or using ICS-LABA combination therapy may be considered 1
• Fractional exhaled nitric oxide (FeNO) measurement can be added as part of an ongoing asthma monitoring and management strategy that includes frequent assessments, but should not be used in isolation 8

Important note on intermittent ICS therapy:

• Intermittent ICS dosing does not apply to ages 5 to 11 years because this therapy has not been adequately studied in this age group 8
• The Expert Panel has made no recommendation for children aged 5 to 11 years with mild persistent asthma regarding intermittent ICS therapy because of insufficient evidence 8

Safety Profile of Inhaled Corticosteroids

The benefits of ICS clearly outweigh concerns about potential adverse effects in children. 3, 9

• Strong evidence from clinical trials following children for up to 6 years suggests that ICS at recommended doses do not have long-term, clinically significant, or irreversible effects on vertical growth, bone mineral density, ocular toxicity, or suppression of adrenal/pituitary axis 1
• A small but statistically significant reduction in growth velocity (0.20 cm/year) was observed when comparing low doses versus low-to-medium doses of ICS over 12 months in school-aged children 6
• This growth effect is small, nonprogressive, and does not outweigh the substantial benefits of asthma control 3, 6
• Use of ICS in school children with asthma is safe with regard to systemic side effects when used in low to medium doses 9

Monitoring and Follow-up

Assess response to therapy within 4-6 weeks, and consider alternative therapies or diagnoses if clear benefit is not observed within this timeframe. 1

• Once control is established and sustained, a careful step-down in therapy should be attempted 1
• Regular follow-up is essential to ensure that the treatment regimen remains appropriate 8
• For children with frequent exacerbations despite ICS therapy, step-up options include increasing ICS dose, adding LABA for children 4 years and older, or adding LTRA 1