What is the recommended treatment for a 13-month-old patient with asthma?

Asthma Treatment for a 13-Month-Old

For a 13-month-old with asthma, initiate treatment with an inhaled short-acting beta-agonist (albuterol/salbutamol) as needed for symptom relief, and if symptoms occur more than 2 days per week, add a daily controller medication—preferably an inhaled corticosteroid or montelukast as an alternative. 1, 2

Controller Therapy Selection

Daily controller medication is indicated if the child experiences asthma symptoms more than 2 days per week or more than 2 nights per month. 2

First-Line Controller Options:

• Inhaled corticosteroids (ICS) are the preferred daily controller therapy for persistent asthma in all age groups, including infants 2
• Montelukast is FDA-approved for children ≥12 months of age and represents a practical alternative, particularly valued for ease of daily oral dosing in this age group 3, 2
  • Dosing: 4 mg oral granules once daily for children 12-23 months 3
  • The oral granule formulation can be mixed with soft foods or liquids for ease of administration 3

Delivery Device Considerations:

• For children under 2 years, use a metered-dose inhaler (MDI) with a large-volume spacer and face mask for delivering inhaled medications 1, 4
• MDI with spacer is equally effective to nebulization and may result in lower admission rates with fewer cardiovascular side effects 1
• Most children cannot achieve proper coordination for unmodified MDI use at this age 1

Acute Exacerbation Management

Recognition of Severe Exacerbation:

Identify children requiring immediate aggressive treatment by these clinical features: 5, 1

• Too breathless to feed
• Respiratory rate >50 breaths/minute
• Pulse >140 beats/minute
• Agitation or altered consciousness

Immediate Treatment Protocol for Acute Exacerbations:

1. High-flow oxygen via face mask to maintain SaO₂ >92% 1, 4

2. Salbutamol 2.5 mg via nebulizer (half the standard 5 mg dose for very young children) every 20 minutes for up to 3 doses 1, 4

   • Alternative: 4-8 puffs via MDI with spacer every 20 minutes for 3 doses 1

3. Oral prednisolone 1-2 mg/kg (maximum 60 mg) immediately if the child can swallow 1, 4

   • If vomiting or unable to take oral medications, give IV hydrocortisone 200 mg 1
   • Do not delay systemic corticosteroids—they should be given immediately upon recognition of acute severe asthma 1

4. Add ipratropium 100 mcg to nebulizer if initial beta-agonist treatment fails, repeat every 6 hours 1, 4

   • The combination of beta-agonist plus ipratropium reduces hospitalizations, particularly in severe airflow obstruction 1

Reassessment and Monitoring:

• Repeat clinical assessment 15-30 minutes after starting treatment 1, 4
• Maintain continuous pulse oximetry with target >92% 1, 4
• Response to treatment in the emergency department is a better predictor of hospitalization need than initial severity 1

Common Pitfalls to Avoid

• Do not delay systemic corticosteroids while continuing repeated doses of albuterol alone—failure to respond to two doses within 24 hours signals treatment failure requiring escalation 1
• Do not use antibiotics unless bacterial infection is confirmed—viral respiratory infections are the most common trigger for asthma exacerbations in this age group 1
• Avoid aggressive hydration, methylxanthines, chest physiotherapy, mucolytics, and sedation in pediatric asthma exacerbations 1
• Ensure proper inhaler technique and age-appropriate device before escalating therapy 1

Hospital Admission Criteria

Admit if: 1, 4

• Persistent features of severe asthma after initial treatment
• Failure to respond to initial treatment within 15-30 minutes
• Parents unable to give appropriate treatment at home
• Afternoon or evening presentation with severe symptoms

Discharge Planning and Follow-Up

Discharge Criteria:

• On discharge medication for 24 hours with proper technique verified 1, 4
• Treatment plan includes both bronchodilators and controller therapy (inhaled or oral corticosteroids) 1, 4
• Written action plan provided detailing when to increase bronchodilators and when to seek immediate care 1

Follow-Up:

• GP follow-up within 1 week 1, 4
• Respiratory clinic follow-up within 4 weeks 1, 4
• Prescription of inhaled corticosteroids if not already on controller therapy 1

Key Clinical Considerations

Viral respiratory infections are the most common trigger for asthma exacerbations in this age group—typical history includes recurrent episodes of wheezing and/or cough triggered by viral upper respiratory infection, with recovery taking longer than the usual week 1, 2

The pharmacokinetics of montelukast show higher systemic exposure in children 6-11 months (60% higher AUC, 89% higher Cmax) compared to adults, though safety and tolerability remain similar 3