What is the recommended treatment for pediatric asthma?

Recommended Treatment for Pediatric Asthma

Low-dose inhaled corticosteroids (ICS) are the first-line, most effective treatment for persistent asthma in children of all ages, superior to all other long-term controller medications in reducing exacerbations, improving lung function, and decreasing hospitalizations. 1, 2

Treatment Algorithm by Age and Severity

Children Under 5 Years of Age

Initiate daily ICS when:

• Symptoms require treatment more than 2 times per week 2
• Severe exacerbations require beta₂-agonist more frequently than every 4 hours over 24 hours 3
• More than 3 episodes of wheezing in the past year lasting >1 day and affecting sleep, PLUS risk factors (parental asthma history, atopic dermatitis, OR two of: allergic rhinitis, >4% peripheral eosinophilia, wheezing apart from colds) 3, 1

Preferred delivery methods:

• Budesonide nebulizer solution (FDA-approved ages 1-8 years) 3
• Fluticasone DPI (FDA-approved ages ≥4 years) 3
• MDI with valved holding chamber with or without face mask 3, 2

Alternative therapies (when ICS cannot be used):

• Montelukast 4 mg chewable tablet (FDA-approved ages ≥2 years) 3, 4
• Cromolyn (though inconsistently effective in children <5 years) 3

Critical monitoring:

• Assess response within 4-6 weeks 3, 2
• Stop treatment if no clear benefit within 4-6 weeks and reconsider diagnosis 3, 2
• Attempt step-down after 2-4 months of sustained control 3

Children 5-11 Years of Age

First-line therapy:

• Low-dose ICS via MDI with spacer or DPI 1, 2
• Demonstrated improvements in prebronchodilator FEV₁, reduced airway hyperresponsiveness, fewer oral corticosteroid courses, and decreased hospitalizations compared to as-needed beta₂-agonists alone 3, 2

Alternative controllers (listed alphabetically):

• Cromolyn 3, 2
• Leukotriene receptor antagonists (montelukast) 3, 2
• Nedocromil 3, 2
• Sustained-release theophylline (with serum monitoring) 2

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

For children under 4 years with inadequate control on low-dose ICS:

• Preferred option: Increase ICS dose to medium range (most effective in reducing exacerbations) 1
• Alternative: Add long-acting beta₂-agonist to low-dose ICS 1
• Not preferred: Add LTRA or theophylline (with serum monitoring) to low-to-medium dose ICS 1

For children ≥4 years:

• Increase ICS dose 1
• Add LABA (salmeterol DPI FDA-approved ages ≥4 years) 3, 1
• Add LTRA 1

Critical Safety Considerations

ICS safety profile (low-to-medium doses):

• No clinically significant effects on hypothalamic-pituitary-adrenal axis function in most children 2, 5
• Growth velocity reduction is small and nonprogressive 2
• Strong evidence from 6-year trials shows no long-term, clinically significant, or irreversible effects on vertical growth, bone mineral density, ocular toxicity, or adrenal/pituitary axis suppression at recommended doses 1, 6

Minimize systemic effects:

• Titrate to lowest effective dose to maintain control 1, 2
• Use mouth rinsing after each treatment 2, 5
• Select agents with efficient first-pass hepatic inactivation 6

High-dose ICS caution:

• Dose-related increased risk of systemic effects 5
• Adrenal insufficiency is rare and confined to high doses 6

Common Pitfalls and How to Avoid Them

Never use LABAs as monotherapy:

• LABAs should NEVER be used alone and only in combination with ICS for moderate-to-severe asthma not controlled on low-dose ICS 2

Not all wheezing is asthma:

• Viral respiratory infections are the most common cause of wheezing in preschool-aged children 1
• Consider alternative diagnoses if no response to therapy within 4-6 weeks 3, 2

Underdiagnosis and undertreatment:

• Early recognition and appropriate treatment of high-risk children may result in secondary prevention and improved long-term outcomes 1

Theophylline risks in young children:

• Not recommended as alternative for mild persistent asthma in young children due to particular risks with febrile illnesses (which increase theophylline concentrations) 3
• May be considered as adjunctive therapy only if serum concentrations will be carefully monitored 3

Delivery technique matters:

• Poor inhaler technique reduces efficacy and increases systemic exposure 6, 7
• Consider LTRA trial in children ≥2 years when inhaled medication delivery is suboptimal due to poor technique or adherence 3

Special Considerations

Exercise-induced symptoms:

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

Allergic asthma (ages ≥5 years with controlled symptoms):

• Subcutaneous immunotherapy may be considered as adjunct treatment 1

Concomitant inhaled corticosteroid use:

• Addition of montelukast to ICS resulted in 47% reduction in mean ICS dose compared with 30% in placebo group 4
• Approximately 40% of montelukast-treated patients could be tapered off ICS versus 29% placebo-treated patients 4