What are the latest Global Initiative for Asthma (GINA) guidelines for managing asthma in pediatric patients?

Latest GINA Guidelines for Pediatric Asthma Management

Assessment of Asthma Control

The most recent GINA guidelines emphasize a control-based approach to pediatric asthma management, categorizing children into age-specific groups (0-4 years, 5-11 years, and 12+ years) with distinct assessment criteria for well-controlled, not well-controlled, and very poorly controlled asthma. 1

Children Aged 0-4 Years

• Daytime symptoms: Well-controlled = ≤2 days/week; Not well-controlled = >2 days/week; Very poorly controlled = throughout the day 1
• Nighttime awakenings: Well-controlled = ≤1 time/month; Not well-controlled = >1 time/month; Very poorly controlled = >1 time/week 1
• Short-acting β2-agonist use: Well-controlled = ≤2 days/week; Not well-controlled = >2 days/week; Very poorly controlled = several times per day 1
• Exacerbations requiring oral corticosteroids: Well-controlled = 0-1/year; Not well-controlled = 2-3/year; Very poorly controlled = >3/year 1

Children Aged 5-11 Years

• Daytime symptoms: Well-controlled = ≤2 days/week (not more than once daily); Not well-controlled = >2 days/week or multiple times on ≤2 days/week; Very poorly controlled = throughout the day 1
• Nighttime awakenings: Well-controlled = ≤1 time/month; Not well-controlled = ≥2 times/month; Very poorly controlled = ≥2 times/week 1
• Lung function (FEV1 or peak flow): Well-controlled = >80% predicted; Not well-controlled = 60-80% predicted; Very poorly controlled = <60% predicted 1
• FEV1/FVC ratio: Well-controlled = >80%; Not well-controlled = 75-80%; Very poorly controlled = <75% 1

Stepwise Treatment Approach by Age Group

Ages 0-4 Years: Recurrent Wheezing Management

For children aged 0-4 years with recurrent wheezing triggered by respiratory tract infections and no wheezing between infections, start a short course of daily inhaled corticosteroids at the onset of respiratory infection with as-needed short-acting β2-agonist (SABA), rather than SABA alone. 1

• This recommendation carries high certainty of evidence despite being a conditional recommendation 1
• Diagnosis in this age group relies almost entirely on symptoms rather than objective lung function tests 1, 2
• Recurrent wheeze is often associated with viral respiratory infections, frequently without family history of asthma or atopy 1
• FeNO measurement is NOT recommended to predict future development of asthma in this age group (strong recommendation against) 1

Ages 4-11 Years: Controller Therapy Options

For children aged 4 years and older with moderate to severe persistent asthma, ICS-formoterol in a single inhaler used as both daily controller and reliever therapy is strongly recommended over either higher-dose ICS alone or same-dose ICS-LABA with separate SABA. 1

• This carries strong recommendation with high certainty of evidence for ages >12 years and moderate certainty for ages 4-11 years 1
• However, formoterol via dry powder inhaler is NOT approved for children aged 5-11 years due to insufficient inspiratory flow generation and lack of safety data 3
• For children under 4 years, formoterol is completely contraindicated and not available 3

For mild to moderate persistent asthma in adherent patients aged 4 years and older, do NOT routinely increase ICS dose short-term for increased symptoms or decreased peak flow (conditional recommendation, low certainty of evidence). 1

Step 3 Treatment Options for Ages 6-11 Years

Recent evidence from 2023 comparing GINA step 3 options shows:

ICS-LABA combination therapy achieves the best outcomes in children aged 6-11 years, followed by ICS-LTRA, then medium-dose ICS alone. 4

• ICS-LABA group had significantly fewer ER visits (1.75±0.96 vs 2.93±1.41 vs 3.11±1.21, p<0.001) 4
• Fewer admissions per year (1.52±1.02 vs 1.96±0.84 vs 2.06±1.07, p=0.047) 4
• Lower PICU admission rates (13.88% vs 26.47% vs 39.39%, p=0.034) 4
• Best lung function values at 3-month follow-up 4

Ages 12 Years and Older

For adolescents aged 12+ years with mild persistent asthma, either daily low-dose ICS with as-needed SABA OR as-needed ICS and SABA used concomitantly are conditionally recommended (moderate certainty of evidence). 1

For moderate to severe persistent asthma in ages 12+, ICS-formoterol as single-inhaler maintenance and reliever therapy (SMART) is conditionally recommended over higher-dose ICS-LABA with separate SABA (high certainty of evidence). 1

Adjunctive Therapies

Subcutaneous Immunotherapy (SCIT)

For children aged 5 years and older with mild to moderate allergic asthma, SCIT is conditionally recommended as adjunct treatment ONLY when asthma is controlled during initiation, build-up, and maintenance phases (moderate certainty of evidence). 1

• SCIT must be administered in clinical settings capable of monitoring and treating reactions, never at home 1
• Sublingual immunotherapy (SLIT) is NOT recommended for asthma treatment 1

Fractional Exhaled Nitric Oxide (FeNO) Testing

For children aged 5+ years with persistent allergic asthma where uncertainty exists in choosing or adjusting anti-inflammatory therapy, FeNO measurement is conditionally recommended as part of an ongoing monitoring strategy with frequent assessments (low certainty of evidence). 1

• FeNO should NOT be used in isolation to assess control, predict exacerbations, or assess exacerbation severity (strong recommendation against) 1
• FeNO cut-off of 25 ppb is recommended based on recent evidence 1
• For diagnostic purposes when asthma diagnosis is uncertain, FeNO can be used as an adjunct (moderate certainty of evidence) 1

Long-Acting Muscarinic Antagonists (LAMA)

For adolescents aged 12+ years with uncontrolled persistent asthma, do NOT add LAMA to ICS instead of adding LABA to ICS (conditional recommendation against, moderate certainty). 1

However, if LABA is not used, adding LAMA to ICS is conditionally recommended over continuing same-dose ICS alone. 1

For uncontrolled asthma on ICS-LABA, adding LAMA to ICS-LABA is conditionally recommended (moderate certainty of evidence). 1

Allergen Mitigation Strategies

For children with asthma who have symptoms related to identified indoor allergens confirmed by history or testing, use multicomponent allergen-specific mitigation interventions (conditional recommendation, low certainty). 1

• For pest sensitization (cockroaches/rodents), integrated pest management alone or as part of multicomponent intervention is conditionally recommended 1
• For dust mite sensitization, impermeable pillow and mattress covers ONLY as part of multicomponent intervention 1
• For children without specific allergen sensitization or symptoms, allergen-mitigation is NOT recommended as routine management 1

Medication Delivery Considerations

Most children cannot properly use unmodified metered-dose inhalers and should use large volume spacer devices to enhance medication deposition. 2

Age-Appropriate Device Selection:

• Ages 0-4 years: MDI with spacer and mask 2
• Ages 5+ years: MDI with spacer OR dry powder inhaler 2
• Nebulizers can be replaced by spacer devices in many cases 2

Exacerbation Management

For acute exacerbations, short courses of oral corticosteroids (1-2 mg/kg for 1-5 days) with no tapering are recommended. 2

Indications include:

• Worsening symptoms despite increased bronchodilator use 2
• Sleep disturbance from asthma 2
• Diminishing response to bronchodilators 2

Oxygen supplementation is recommended for moderate to severe exacerbations, targeting oxygen saturation 92-95%. 1

Risk Factors for Exacerbations

Key risk factors consistently identified across guidelines include:

• Allergen exposure and environmental tobacco smoke (12 guidelines) 1
• Air pollution (9 guidelines) 1
• Hospitalizations or ED visits for asthma in the last year 1
• Poor inhaler technique 1
• Poor asthma control, underuse or poor adherence to treatment 1
• Comorbidities and NSAID use 1

Self-Management and Education

GINA emphasizes enabling parents to manage treatment rather than requiring doctor consultation before making changes. 1, 2

Essential education components:

• Training in proper inhaler use and peak flow meter technique 1, 2
• Understanding difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory treatment) 1, 2
• Recognition of worsening asthma signs, especially nocturnal symptoms 1, 2
• Written action plans with prearranged patient actions 1, 2

Monitoring and Follow-Up

Treatment outcomes should be assessed regularly, focusing on minimal daytime symptoms, no nighttime waking, no missed school, full participation in activities/sports, and infrequent need for relief medications. 1, 2

• Regular height and weight monitoring is essential, as asthma itself can delay growth and puberty, but catch-up growth typically occurs 1, 2
• Inhaled corticosteroids at doses >400 µg/day have shown short-term reductions in tibial growth rate, but these cannot be extrapolated to long-term effects 1
• Step down therapy after 6-12 months of disease stability 1

Critical Safety Warnings

Long-acting beta-agonists (LABAs) including formoterol have FDA warnings for increased risk of severe exacerbations and deaths when used as monotherapy and should ONLY be used in combination with inhaled corticosteroids. 3, 5

• Formoterol is NOT approved for children under 12 years via metered-dose inhaler 3, 5
• Children under 4 years cannot generate sufficient inspiratory flow for adequate medication delivery 3, 5
• The bronchoprotective effect of formoterol decreases rapidly with regular use 3