What is the recommended dosage of fluticasone (inhaled corticosteroid) for a 4-year-old?

Fluticasone Dosing for a 4-Year-Old with Asthma

For a 4-year-old child with asthma, start with fluticasone 100 mcg twice daily (total 200 mcg/day) as the preferred low-dose inhaled corticosteroid for mild persistent asthma, delivered via metered-dose inhaler with a spacer device. 1

Initial Dosing Strategy

• Low-dose fluticasone (100-200 mcg/day total) is the preferred first-line controller therapy for mild persistent asthma (Step 2 care) in children aged 4 years and older 2, 1
• The practical dosing is 1 spray (50 mcg) in each nostril twice daily when using the standard MDI formulation, achieving 200 mcg total daily dose 3
• Clinical studies demonstrate that 100-200 mcg/day represents a "plateau" of efficacy for most children, with minimal additional benefit from higher doses 4

Delivery Method Requirements

• Always use a large volume spacer device with MDI to enhance lung deposition and reduce local side effects in young children 2, 1
• For a 4-year-old, ensure the face mask fits snugly over nose and mouth when using the spacer 1
• Have the child rinse mouth and spit after each use to prevent oral thrush (candidiasis) 1, 3

Stepwise Escalation if Needed

If asthma remains uncontrolled after 4-6 weeks on low-dose therapy:

• Step 3 care options include either:
  • Increasing to medium-dose fluticasone (>176-352 mcg/day for ages 5-11, extrapolated to age 4), OR
  • Adding a long-acting beta-agonist to low-dose ICS 2, 1
• Medium-dose monotherapy is a preferred option in children under 5 years since long-acting beta-agonists lack safety data in this age group 2
• Studies show medium doses are most effective at reducing asthma exacerbations specifically 2

Critical Safety Considerations

• Do not exceed 200 mcg/day initially without specialist consultation, as doses >500 mcg/day for prolonged periods risk adrenal suppression, growth velocity reduction, and cases of acute adrenal crisis have been reported 4
• Monitor growth velocity even at moderate doses, though effects are typically small (approximately 1 cm) and non-progressive 1, 4
• Reassess every 2-6 weeks initially; if no clear benefit within 4-6 weeks, discontinue and consider alternative diagnoses 2, 1
• Step down therapy after 2-4 months of sustained control to find the minimum effective dose 2, 4

Common Pitfalls to Avoid

• Never use fluticasone without a spacer in a 4-year-old—technique is inadequate and lung deposition poor 2
• Avoid starting with high doses (>200 mcg/day)—they do not achieve faster control and expose to unnecessary systemic effects 4
• Do not continue therapy indefinitely without reassessment—the goal is minimal effective dose 2, 4
• Watch for local side effects including cough, dysphonia, and oral candidiasis, which are preventable with proper mouth rinsing 1, 3

Treatment Goals

The outcome of successful management should be:

• Minimal daytime symptoms and no nighttime awakening 2
• No missed playgroup/nursery days and full participation in activities 2
• Infrequent need for rescue bronchodilators 2