Pediatric Asthma Medication Dosing
For children with persistent asthma, low-dose inhaled corticosteroids (ICS) are the preferred first-line controller therapy, with specific dosing determined by age, severity, and the ICS molecule selected. 1
Age-Specific Dosing Recommendations
Children 5 Years and Older
Mild Persistent Asthma:
- Low-dose ICS is the preferred therapy delivered via metered-dose inhaler with spacer, dry powder inhaler, or nebulizer 1
- Alternative options include leukotriene receptor antagonists (montelukast), cromolyn, or nedocromil, though these are less effective than ICS 1
Moderate Persistent Asthma:
- Add a long-acting beta2-agonist (LABA) to low-dose ICS, OR increase ICS to medium-dose range 1
- For fluticasone-salmeterol combination: 100 mcg/50 mcg one inhalation twice daily (approximately 12 hours apart) for children aged 4-11 years 2
- For adolescents 12 years and older: dosing ranges from 100 mcg/50 mcg to 500 mcg/50 mcg twice daily depending on disease severity 2
Children Under 5 Years
- Low-dose ICS remains the preferred therapy delivered via nebulizer, dry powder inhaler, or metered-dose inhaler with holding chamber 1
- Alternative therapies include cromolyn or montelukast (approved for children ≥12 months) 1, 3
- Nebulized bronchodilator dosing: salbutamol 2.5 mg for children up to age 2 years, 5 mg for children over age 2 years 4
Acute Severe Asthma Dosing
Immediate Treatment Protocol:
- Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer (half doses in very young children) 4
- Add ipratropium 100 mcg nebulized every 6 hours 4
- Intravenous hydrocortisone for severe presentations 4
- Oral prednisolone 1-2 mg/kg body weight daily (maximum 40 mg) for 1-5 days; no tapering needed 4
Life-Threatening Features:
- Intravenous aminophylline 5 mg/kg over 20 minutes, followed by maintenance infusion of 1 mg/kg/hour in children 4, 5, 6
- Omit loading dose if child already receiving oral theophyllines 4, 5
Molecule-Specific Considerations
The ICS molecule selected significantly impacts growth suppression effects more than dose or device. 7 Different molecules show varying degrees of growth velocity reduction during the first year of treatment, with the effect being maximal in year one and less pronounced in subsequent years 7. However, the small reduction in growth (approximately 0.48 cm/year) is minor compared to the known benefits of asthma control 7.
Monitoring and Adjustment Algorithm
Step-Up Criteria (if control not achieved within 4-6 weeks):
- Add LABA to low-dose ICS, OR
- Increase ICS to medium-dose range, OR
- Add leukotriene receptor antagonist to ICS 1
Step-Down Criteria:
- Attempt after benefits sustained for 2-4 months 1
- Reassess inhaler technique before stepping down 4, 1
Critical Pitfalls to Avoid
Never omit the aminophylline loading dose without confirming theophylline use history - giving a loading dose to a child already on oral theophyllines can cause toxicity 4, 5, 6
Do not use LABA monotherapy - LABAs should only be used in combination with ICS 2
Avoid undertreatment - inadequate control can lead to permanent airway changes, which is a more significant concern than the minimal growth effects of ICS 1
Do not use theophylline as first-line therapy in young children due to risk of adverse effects, particularly during febrile illnesses 1
Verify proper inhaler technique at every visit - poor technique is a common cause of treatment failure 4, 1