What is the recommended treatment for bronchial asthma in children?

Treatment of Bronchial Asthma in Children

Low-dose inhaled corticosteroids are the preferred first-line controller therapy for all children with persistent asthma, starting at age 5 years and older, with alternative therapies including leukotriene receptor antagonists, cromolyn, nedocromil, or theophylline reserved only when ICS cannot be used. 1, 2

Long-Term Controller Therapy by Age Group

Children ≥5 Years with Mild Persistent Asthma

• Preferred therapy: Low-dose inhaled corticosteroids (fluticasone 100 mcg or budesonide equivalent twice daily) 1, 2
• Alternative therapies (listed alphabetically, insufficient data to rank): Cromolyn, leukotriene receptor antagonists (montelukast), nedocromil, or sustained-release theophylline 1, 2
• Strong evidence demonstrates that inhaled corticosteroids improve prebronchodilator FEV1, reduce airway hyperresponsiveness, improve symptom scores, decrease oral corticosteroid courses, and reduce urgent care visits or hospitalizations compared to as-needed beta2-agonists alone 1

Children <5 Years with Persistent Asthma

• Preferred therapy: Low-dose inhaled corticosteroids via nebulizer, dry powder inhaler, or metered-dose inhaler with holding chamber (with or without face mask) 1
• Alternative therapies: Cromolyn or leukotriene receptor antagonist 1
• These recommendations are based on extrapolation from studies in older children, as direct comparative studies are not available in this age group 1

Children with Inadequate Control on ICS Monotherapy

• Step-up therapy: Combination ICS/long-acting beta2-agonist (LABA) for children ≥4 years who remain symptomatic on ICS alone 2, 3
• Available combination products include fluticasone/salmeterol at doses of 100/50,250/50, or 500/50 mcg twice daily, with starting dosage based on asthma severity 3
• Critical warning: Never use LABA as monotherapy without ICS, as LABA monotherapy increases the risk of serious asthma-related events 3

Acute Asthma Exacerbation Management

Recognition of Severe Exacerbation

• Severe features: Too breathless to talk or feed, respiratory rate >50 breaths/min (age <5 years) or >25 breaths/min (older children), pulse >140 beats/min, peak expiratory flow <50% predicted 4, 2
• Life-threatening features: PEF <33% predicted, silent chest, cyanosis, poor respiratory effort, exhaustion, altered consciousness 4, 2

Immediate First-Line Treatment (Simultaneous Administration)

• High-flow oxygen via face mask to maintain SpO2 >92% 4, 2, 5
• Nebulized salbutamol 5 mg (age >2 years) or 2.5 mg (age ≤2 years) via oxygen-driven nebulizer every 20 minutes for 3 doses, OR 4-8 puffs via MDI with large volume spacer every 20 minutes for 3 doses 4, 5
• Oral prednisolone 1-2 mg/kg (maximum 60 mg) as a single dose immediately 4, 2, 5
• Ipratropium bromide 100 mcg added to nebulizer immediately and repeated every 6 hours for moderate to severe exacerbations 4, 2, 5

Critical Treatment Principles

• MDI with large volume spacer is equally effective to nebulization and may result in lower admission rates, particularly in severe exacerbations, with fewer cardiovascular side effects 4
• Do not delay systemic corticosteroids while giving repeated albuterol doses alone—corticosteroids must be given immediately upon recognition of severe asthma 4, 5
• Oral corticosteroids are preferred when the child can swallow and is not vomiting; reserve IV hydrocortisone 200 mg every 6 hours (or 4 mg/kg/dose) for children who are vomiting, seriously ill, or unable to take oral medications 4

Monitoring and Reassessment

• Repeat clinical assessment 15-30 minutes after starting treatment 4, 5
• Monitor respiratory rate, work of breathing, ability to speak/feed, heart rate, oxygen saturation continuously—brief spot-checks are insufficient 5
• Measure peak expiratory flow before and after each bronchodilator dose 4

Hospital Admission Criteria

• Persistent features of severe asthma after initial treatment 4, 2
• Peak expiratory flow remaining <50% predicted 15-30 minutes after nebulization 4
• SpO2 <92% despite treatment, pneumonia with wheezing, or influenza infection 5
• Parents unable to give appropriate treatment at home 4

Discharge Criteria

• On discharge medications for 24 hours with verified inhaler technique 4, 2
• PEF >75% of predicted or personal best 4, 2
• PEF diurnal variability <25% 2
• Prescribed oral steroids, inhaled steroids, and bronchodilators 4, 2
• Written action plan provided 4, 2
• Follow-up with GP within 1 week and respiratory clinic within 4 weeks 4, 2

Comparative Efficacy of Controller Medications

• Inhaled corticosteroids are superior to all other long-term controller medications including cromolyn, nedocromil, theophylline, and leukotriene receptor antagonists in improving asthma outcomes 1
• Montelukast can reduce inhaled corticosteroid requirements by approximately 47% when added to ICS therapy, and approximately 40% of patients may be tapered off ICS entirely 6
• However, patients randomized to treatment arms containing ICS had significantly better asthma control than those on montelukast alone, as measured by FEV1, daytime symptoms, PEFR, nocturnal awakenings, and rescue beta-agonist requirements 6

Safety Considerations for Inhaled Corticosteroids

• Growth effects: Fluticasone propionate 100-200 mcg/day does not cause growth suppression in children with mild asthma 7
• Growth retardation has not been reported when ICS doses ≤400 mcg daily are individually tailored 8
• Beclomethasone dipropionate may cause growth deceleration at 400 mcg/day, especially in children with mild symptoms 7
• HPA-axis suppression: Fluticasone propionate is equipotent to older compounds at half the dose 7
• Monitor for oral candidiasis; advise patients to rinse mouth with water without swallowing after inhalation 3
• Assess bone mineral density initially and periodically, monitor growth in pediatric patients, and consider ophthalmology referral for long-term users due to glaucoma and cataract risk 3

Self-Management Education Components

• Training in proper inhaler technique and peak flow meter use 2
• Understanding the difference between relievers (bronchodilators) and preventers (controllers) 2
• Recognition of worsening asthma signs 2
• Written action plan including: monitoring symptoms, peak flow, and medication use; prearranged patient-initiated actions; written guidance on when to increase ICS, start oral steroids, or seek urgent care 2

Common Pitfalls to Avoid

• Do not use LABA in combination with additional LABA-containing medications due to overdose risk 3
• Do not initiate ICS/LABA combination in acutely deteriorating asthma—not indicated for relief of acute bronchospasm 3
• Do not delay systemic corticosteroids in acute exacerbations while continuing repeated bronchodilator doses alone 4, 5
• Do not use antibiotics unless bacterial infection is confirmed—viral prodrome does not suggest bacterial infection 4
• Ensure proper inhaler technique and age-appropriate device before escalating therapy 4