What treatment guidelines should be followed for a child with asthma experiencing an upper respiratory infection?

Treatment Guidelines for Upper Respiratory Infection in a Child with Asthma

For a child with asthma experiencing an upper respiratory infection, continue their regular controller medications (inhaled corticosteroids if prescribed), optimize bronchodilator therapy with albuterol as needed, and consider early initiation of oral corticosteroids (prednisolone 1-2 mg/kg/day) at the first signs of increased asthma symptoms to prevent progression to acute exacerbation. 1, 2, 3

Understanding the Clinical Context

Viral upper respiratory infections are the most common trigger for asthma exacerbations in children, with approximately 50-80% of children with asthma developing symptoms before age 5 years. 4, 5 Children with asthma characteristically take longer than the usual week to fully recover from respiratory symptoms following a viral URI. 5

Maintenance Controller Therapy During URI

Continue Existing Controller Medications

• Do not discontinue inhaled corticosteroids during a URI - these remain the preferred first-line controller therapy for children with persistent asthma and should be maintained throughout the infection. 4, 6, 5
• For children already on low-dose inhaled corticosteroids (such as fluticasone 100 mcg or budesonide equivalent), continue the current regimen without interruption. 6
• Alternative controllers like montelukast (approved for children ≥12 months) should also be continued if already prescribed. 5

Bronchodilator Management

Rescue Medication Protocol

• Administer albuterol 4-8 puffs via MDI with spacer every 4 hours as needed for symptoms, or 2.5-5 mg via nebulizer. 1
• MDI with large volume spacer is the preferred delivery method as it is equally effective to nebulization and may result in lower admission rates with fewer cardiovascular side effects. 1, 6

Monitoring for Treatment Failure

• If the child requires albuterol more frequently than every 4 hours, or fails to respond to two doses within 24 hours, this signals treatment failure requiring escalation of care. 1

Early Corticosteroid Intervention Strategy

Preventive Approach

• Initiate oral prednisolone 1-2 mg/kg/day (maximum 60 mg/day) at the first signs of increased asthma symptoms during the URI, before wheezing develops. 2, 3
• This preventive strategy has been shown to reduce wheezing days by 65%, attacks by 56%, emergency room visits by 61%, and hospitalizations by 90% in preschool children. 3
• Continue the corticosteroid course for 3-10 days until symptoms resolve or peak expiratory flow reaches 80% of personal best. 2

Dosing Specifics from FDA Guidelines

• Prednisolone dosing: 0.14 to 2 mg/kg/day in three or four divided doses (4 to 60 mg/m²/day). 2
• The National Heart, Lung, and Blood Institute recommends 1-2 mg/kg/day in single or divided doses for children whose asthma is uncontrolled. 2
• There is no evidence that tapering the dose after improvement prevents relapse - simply discontinue when symptoms resolve. 2

Recognition of Acute Severe Exacerbation

Warning Signs Requiring Immediate Escalation

• Too breathless to talk or feed 4, 1, 6
• Respiratory rate >50 breaths/minute 4, 1, 6
• Pulse >140 beats/minute 4, 1, 6
• Peak expiratory flow <50% predicted 4, 1, 6

Immediate Treatment Protocol for Severe Exacerbation

• High-flow oxygen via face mask to maintain SaO₂ >92% 1, 6
• Nebulized salbutamol 5 mg (or 2.5 mg if age ≤2 years) every 20 minutes for up to 3 doses 1
• Oral prednisolone 1-2 mg/kg (max 60 mg) immediately, or IV hydrocortisone 200 mg every 6 hours if vomiting or unable to take oral medications 1, 2
• Add ipratropium 100 mcg nebulized every 6 hours for moderate to severe exacerbations 1, 6

Common Pitfalls to Avoid

• Do not wait for wheezing to develop before starting oral corticosteroids - early intervention at the first signs of increased symptoms (cough, shortness of breath) is more effective. 3, 7
• Do not use antibiotics unless bacterial infection is confirmed - clear rhinorrhea and viral prodrome do not suggest bacterial infection. 1
• Many parents wait for lower respiratory signs (gasping, accessory muscle use) before intensifying treatment, which delays effective intervention. 7
• Do not delay systemic corticosteroids while continuing repeated doses of albuterol alone after treatment failure. 1

Follow-Up and Controller Therapy Adjustment

Initiation of Long-Term Control Therapy

• If the child is not already on controller therapy and has had more than three episodes of wheezing in the past year lasting more than 1 day and affecting sleep, strongly consider initiating daily inhaled corticosteroids as the preferred long-term controller. 4
• Alternative options include cromolyn or leukotriene receptor antagonists (montelukast), though inhaled corticosteroids are preferred. 4, 6

Post-URI Assessment

• Schedule follow-up within 1 week with primary care provider and within 4 weeks with respiratory clinic if exacerbation occurred. 1, 6
• Ensure proper inhaler technique is verified and documented. 4, 1
• Provide written action plan detailing when to increase bronchodilators, start oral steroids, and seek urgent care. 6