Pediatric Asthma Management
Chronic Asthma Management: Stepwise Approach
For children with persistent asthma (symptoms >2 days/week or >2 nights/month), inhaled corticosteroids (ICS) are the preferred first-line daily controller therapy across all pediatric age groups. 1, 2
Age-Specific Medication Delivery
- Ages 0-2 years: Use metered-dose inhaler (MDI) with large volume spacer for all inhaled medications; nebulizers are overused, expensive, time-consuming, and inefficient compared to spacer devices 1, 3
- Ages 3-4 years: Continue MDI with large volume spacer; most children cannot achieve coordination for unmodified MDI use 1, 4
- Ages 5+ years: MDI with spacer remains preferred; some children can use dry powder inhalers (Turbohaler, Diskhaler) 1
Controller Therapy Selection
Inhaled corticosteroids remain the mainstay of preventive treatment, combining effectiveness with relative freedom from side effects and convenient twice-daily dosing. 1
- Use the lowest ICS dose providing acceptable symptom control 1
- Short-term reductions in tibial growth rate occur at doses >400 µg/day, but these cannot be extrapolated to long-term effects 1
- Montelukast is approved for children ≥12 months and offers ease of daily oral dosing as an alternative controller option 5, 2
- Long-acting beta-2 agonists should only be used in combination with ICS, never as monotherapy 2
Treatment Goals and Monitoring
The outcome of successful management should include: 1
- Minimal daytime symptoms and no nocturnal awakening
- No missed school/daycare
- Full participation in activities and sports
- Infrequent need for relief medications
- Normal height and weight velocity documentation
Reassess response within 2-4 weeks of starting controller therapy and ensure proper medication delivery technique before escalating therapy. 3
Acute Asthma Exacerbation Management
Severity Assessment
Immediately identify children requiring aggressive treatment by these clinical features: 4, 6
Severe exacerbation indicators:
- Too breathless to talk or feed 4, 6
- Respiratory rate >50 breaths/minute 4, 6
- Pulse >140 beats/minute 4, 6
- Peak expiratory flow <50% predicted 4, 6
- Oxygen saturation <92% 4, 6
Life-threatening features:
- Peak flow <33% predicted 6
- Silent chest, poor respiratory effort 6
- Cyanosis, exhaustion, altered consciousness 6
Immediate Treatment Protocol
For acute severe asthma, administer systemic corticosteroids immediately upon recognition—do not delay while giving repeated albuterol doses alone. 4
First-Line Emergency Treatment (All Given Simultaneously):
Salbutamol (Albuterol):
- Age ≤2 years: 2.5 mg via nebulizer OR 4-8 puffs via MDI with spacer 4, 3
- Age >2 years: 5 mg via nebulizer OR 4-8 puffs via MDI with spacer 4
- Repeat every 20 minutes for up to 3 doses in first hour 4
- MDI with large volume spacer is equally effective to nebulization and may result in lower admission rates with fewer cardiovascular side effects 4, 3
Systemic Corticosteroids (choose based on clinical status):
Ipratropium bromide 100 mcg added to nebulizer immediately when initial beta-agonist treatment fails, repeated every 6 hours 4, 6
Critical Pitfall to Avoid
Do not delay systemic corticosteroids while continuing repeated albuterol doses alone—failure to respond to two doses within 24 hours signals treatment failure requiring escalation. 4 Underuse of corticosteroids is a major factor in preventable asthma deaths. 6
Monitoring and Reassessment
- Repeat peak expiratory flow measurement 15-30 minutes after starting treatment 4, 6
- Maintain continuous pulse oximetry with target >92% 4, 6
- Response to treatment in the emergency department is a better predictor of hospitalization need than initial severity 4
If Not Improving After Initial Treatment:
- Continue oxygen and steroids 6
- Increase nebulized beta-agonist frequency to every 30 minutes 6
- Consider IV magnesium sulfate for life-threatening exacerbations or those remaining severe after 1 hour of intensive conventional treatment 4
Hospital Admission Criteria
- Persistent features of severe asthma after initial treatment
- Peak expiratory flow remaining <50% predicted 15-30 minutes after treatment
- Parents unable to give appropriate treatment at home
- Afternoon or evening presentation
Discharge Criteria
Children can be discharged when: 4, 6
- On discharge medication for 24 hours with proper inhaler technique verified
- Peak flow >75% of predicted with diurnal variability <25%
- Treatment includes oral steroids and inhaled steroids in addition to bronchodilators
- Written action plan provided to parents
- GP follow-up arranged within 1 week and respiratory clinic follow-up within 4 weeks
Home Management of Worsening Symptoms
When yellow zone symptoms appear, parents should: 4
- Administer 4-8 puffs salbutamol via MDI with spacer every 20 minutes for up to 3 doses
- Start oral prednisone 1-2 mg/kg immediately
- Reassess 15-30 minutes after each bronchodilator dose
Seek immediate medical care if: 4
- Child cannot complete sentences in one breath
- Pulse >110 bpm or respiratory rate >25/minute persists
- Child appears exhausted, drowsy, or confused
Special Considerations for Very Young Children (0-2 Years)
Particular challenges in this age group include: 1
- Recurrent wheeze/cough often associated with viral infections without family history of asthma/atopy
- Diagnosis relies almost entirely on symptoms rather than objective lung function tests
- Variable bronchodilator response in first year of life, but bronchodilators should still be tried 1
- Other disorders may mimic asthma: gastroesophageal reflux, cystic fibrosis, chronic lung disease of prematurity 1
For acute symptoms in infants, underestimating severity is a critical pitfall—assessment can be difficult, and any concerning features should prompt aggressive treatment. 3
What NOT to Do
Avoid these interventions in pediatric asthma exacerbations: 4
- Antibiotics (unless bacterial infection confirmed)
- Aggressive hydration in older children
- Methylxanthines
- Chest physiotherapy
- Mucolytics
- Sedation