What is the recommended management approach for asthma in children?

Management of Asthma in Children

Childhood asthma management follows a stepwise approach prioritizing inhaled corticosteroids as the cornerstone of preventive therapy, combined with short-acting beta-agonists for symptom relief, delivered via metered-dose inhalers with large volume spacers for optimal drug deposition. 1, 2

Diagnostic Assessment and Monitoring

Key diagnostic indicators include:

• Family history of asthma or atopy, recurrent wheezing episodes, persistent or recurrent cough, and symptoms triggered by viral infections or allergens 2
• Assessment should focus on frequency of daytime and nighttime symptoms, impact on school attendance, need for rescue medication, and lung function measurements in children ≥5 years 2
• Regular monitoring of height and weight velocities is essential, as asthma itself can delay growth and puberty, though catch-up growth typically occurs 1, 2

Treatment outcome assessment should include: 1, 2

• Days missed from school since last visit
• Amount of daytime and nighttime cough
• Frequency of relief medication use
• Activity limitations and wheeze
• Appropriateness of inhaler device for age and proper technique

Medication Delivery Systems

Most children cannot achieve the coordination necessary to use an unmodified metered-dose inhaler (MDI); this should not be used unless there is certainty about the child's technique. 1, 3

Age-appropriate delivery devices: 1, 2, 3

• 0-4 years: MDI with large volume spacer and face mask
• 5+ years: MDI with large volume spacer or dry powder inhaler (Turbohaler or Diskhaler)
• Every child given inhaled steroids from an MDI should use a large volume spacer to enhance deposition of medication in the lungs 1

Important considerations:

• Nebulizers are overused both in hospital and community settings; they are expensive, time-consuming, and inefficient, and may often be replaced by large volume spacer devices 1
• When using large volume spacers, actuate the MDI, breathe in one puff, repeat actuation, then breathe in the second puff, continuing until the appropriate number of puffs has been inhaled 1

Stepwise Pharmacologic Management

Chronic Asthma Control

Inhaled corticosteroids are the mainstay of preventive treatment, combining effectiveness, relative freedom from side effects, and the convenience of twice daily treatment. 1

Key principles:

• Use the lowest dose that provides acceptable control of symptoms 1
• Short-term reductions in tibial growth rate have been shown when inhaled steroids are used at doses greater than 400 µg/day, but these short-term reductions cannot be extrapolated to the long term 1
• There is no convincing evidence in children of any important differences between currently available inhaled corticosteroid preparations in their duration of action or side effects 1

Before stepping up therapy, ensure: 1

• The child is using an inhaler appropriate to his or her age
• Inhaler technique is good
• Parents fully understand the principles of management

Goals of successful management: 1

• Minimal symptoms during the day and no waking at night
• No missed playgroup, nursery, or school
• Full participation in activities and sports
• Relatively infrequent need for relief medications

Relief Medications

Short-acting beta-agonists (salbutamol/albuterol) are the preferred relief medications: 2, 3, 4

• Relief treatment outside hospital can be repeated 2-4 hourly 1, 2
• Failure to respond or early deterioration requires immediate medical assessment 1, 2
• Most patients exhibit onset of improvement in pulmonary function within 5 minutes, with maximum improvement at approximately 1 hour 4
• Clinically significant improvement (≥15% increase in FEV1) continues for 3-4 hours in most patients and up to 6 hours in some 4

Additional Controller Options

Long-acting medications for persistent symptoms include: 5

• Long-acting beta-agonists
• Cromolyn sodium and nedocromil
• Antileukotriene agents (montelukast) 6
• Theophylline

Montelukast considerations: 6

• Demonstrated efficacy in pediatric patients 6-14 years of age with mean baseline FEV1 of 72% predicted
• Resulted in 8.7% improvement in mean morning FEV1 versus 4.2% with placebo
• Decreased asthma exacerbation days from 25.7% to 20.6%
• Can add to the clinical effect of inhaled corticosteroids and allow corticosteroid tapering

Management in Very Young Children (0-2 Years)

Particular challenges in this age group: 1, 2

• Recurrent wheeze and cough are associated with viral respiratory infections, often without family history of asthma or atopy
• Diagnosis relies almost entirely on symptoms rather than objective lung function tests
• Paucity of suitably designed controlled trials of treatment
• Bronchodilator response is variable in the first year of life, but bronchodilators should still be tried 1

Acute Exacerbation Management

Recognition of Acute Severe Asthma

Clinical features indicating severe exacerbation: 1, 3

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

Life-threatening features: 1, 3

• PEF <33% predicted or best
• Poor respiratory effort, silent chest, or cyanosis
• Fatigue, exhaustion, agitation, or reduced level of consciousness

Immediate Treatment Protocol

First-line therapy for acute severe asthma: 1, 3

1. High-flow oxygen via face mask to maintain SaO2 >92%
2. Salbutamol 5 mg (or terbutaline 10 mg) via oxygen-driven nebulizer (half doses in very young children), OR 4-8 puffs via MDI with spacer every 20 minutes for up to 3 doses 3
3. Intravenous hydrocortisone OR oral prednisolone 1-2 mg/kg (maximum 40-60 mg) 1, 3
4. Add ipratropium 100 mcg nebulized every 6 hours 1, 3

Important note: Oral corticosteroids are preferred when the child can swallow and has no vomiting, as there is no advantage to intravenous administration when gastrointestinal transit is normal 3

If life-threatening features are present:

• Give intravenous aminophylline 5 mg/kg over 20 minutes followed by maintenance infusion 1 mg/kg/hour 1
• Omit loading dose if child already receiving oral theophyllines 1

Subsequent Management

If patient is improving: 1

• Continue high-flow oxygen
• Prednisolone 1-2 mg/kg body weight daily (maximum 40 mg)
• Nebulized beta-agonist 4 hourly

If patient is NOT improving after 15-30 minutes: 1

• Continue oxygen and steroids
• Give nebulized beta-agonist more frequently, up to every 30 minutes
• Add ipratropium to nebulizer and repeat 6 hourly until improvement starts

Monitoring During Acute Treatment

Essential monitoring parameters: 1, 3

• Repeat peak expiratory flow measurement after starting treatment (if appropriate)
• Oximetry to maintain SaO2 >92%
• Chart PEF before and after beta-agonist administration at least 4 times daily throughout hospital stay

Discharge Criteria

Children can be discharged when: 1, 3

• Been on discharge medication for 24 hours with inhaler technique checked and recorded
• PEF >75% of predicted or best with diurnal variability <25%
• Treatment includes oral steroid tablets and inhaled steroids in addition to bronchodilators
• Own PEF meter provided (if appropriate) with self-management plan or written instructions for parents
• GP follow-up arranged within 1 week
• Follow-up appointment in respiratory clinic within 4 weeks

ICU Transfer Criteria

Transfer to intensive care unit if: 1

• Deteriorating PEF or worsening exhaustion
• Feeble respirations, persistent hypoxia or hypercapnia
• Confusion, drowsiness, coma, or respiratory arrest

Patient and Family Education

Essential education components: 2, 3

• Enable parents to manage treatment independently
• Provide written action plans detailing when to increase bronchodilators and when to seek immediate care
• Educate on proper inhaler technique
• Teach peak flow monitoring in children ≥5 years
• Ensure medications are varied according to symptoms or PEF recordings
• Provide written treatment changes (e.g., on National Asthma Campaign card)
• Ensure child or family knows when to call for help

Common Pitfalls to Avoid

Critical errors in management: 1, 3

• Using unmodified MDIs in children who cannot demonstrate proper technique
• Overusing nebulizers when large volume spacers would be equally or more effective
• Failing to use large volume spacers with inhaled corticosteroids
• Delaying systemic corticosteroids while continuing repeated doses of albuterol alone during acute exacerbations
• Using antibiotics without confirmed bacterial infection (clear rhinorrhea and viral prodrome do not suggest bacterial infection) 3
• Underestimating severity in very young children where assessment may be difficult 1