What is the recommended management and treatment approach for asthma in children?

Management and Treatment of Asthma in Children

Inhaled corticosteroids (ICS) are the preferred first-line long-term controller medication for all children with persistent asthma, starting at low doses and titrating to the minimum effective dose needed to maintain control. 1

Identifying Children Who Need Long-Term Controller Therapy

Initiate daily long-term controller therapy in children with any of the following:

• Frequent wheezers (>3 episodes in past year lasting >1 day and affecting sleep) PLUS high-risk factors: parental asthma or physician-diagnosed atopic dermatitis, OR two of: allergic rhinitis, >4% peripheral blood eosinophilia, or wheezing apart from colds 1
• Symptomatic treatment needed >2 times per week consistently 1
• Severe exacerbations requiring beta2-agonist more frequently than every 4 hours over 24 hours, occurring <6 weeks apart 1
• Symptoms present >2 days/week or >2 nights/month (defines persistent asthma) 2

Stepwise Pharmacologic Approach

Step 1: Preferred Controller Medications

Inhaled corticosteroids are the preferred treatment option when initiating long-term control therapy 1. The benefits outweigh concerns about potential small, nonprogressive reduction in growth velocity 1.

Age-specific FDA-approved options:

• Budesonide nebulizer solution: ages 1-8 years 1
• Fluticasone dry powder inhaler: ≥4 years 1
• Montelukast (LTRA): chewable tablets 2-6 years; granules ≥1 year 1, 3

Alternative options (when ICS cannot be used): cromolyn or leukotriene receptor antagonists (montelukast) 1

Step 2: When Low-Dose ICS Is Insufficient

If control is not achieved on low-dose ICS within 4-6 weeks with good adherence and technique, consider:

Preferred options:

• Increase ICS to medium dose (particularly effective for reducing exacerbations in young children) 1
• Add long-acting beta2-agonist (LABA) to low-dose ICS for children ≥4 years (salmeterol FDA-approved ≥4 years) 1, 4

The combination approach is favored to avoid potential dose-related side effects of higher ICS doses, though medium-dose ICS monotherapy is also a valid preferred option based on efficacy data in young children 1.

Alternative options: Add LTRA or theophylline (with serum monitoring) to low-to-medium dose ICS 1

Critical Caveat: Never Use LABA as Monotherapy

LABAs must ALWAYS be used in combination with ICS, never alone, as LABA monotherapy increases the risk of serious asthma-related events 4. Do not use in combination with additional LABA-containing medications due to overdose risk 4.

Age-Specific Delivery Considerations

Children <4 years: Use face mask with either nebulizer OR metered-dose inhaler (MDI) with valved holding chamber (spacer) 1

All children using MDI with ICS: Must use large volume spacer to enhance lung deposition and reduce oral candidiasis risk 1

Avoid unmodified MDI unless certain of child's coordination ability 1

Nebulizers are overused—large volume spacer devices can often replace them and are more efficient 1

Monitoring and Dose Adjustment

Reassess response within 4-6 weeks of initiating or changing therapy 1. If no clear benefit with satisfactory technique and adherence, discontinue and consider alternative therapies or diagnoses 1.

Once control is established and sustained, attempt careful step-down to find the minimum effective dose 1

Monitor at each visit:

• Days missed from school 1
• Daytime and nighttime symptoms 1
• Frequency of relief medication use 1
• Activity limitation 1
• Height and weight velocities (growth monitoring) 1

ICS Safety Profile

Growth effects: Short-term reductions in tibial growth rate occur at doses >400 mcg/day, but these cannot be extrapolated to long-term effects 1. Strong evidence following children up to 6 years shows no long-term, clinically significant, or irreversible effects on growth, bone mineral density, ocular toxicity, or adrenal suppression at recommended doses 1.

Use lowest effective dose to maintain control 1. Asthma itself delays growth and puberty, with eventual catch-up growth 1.

Monitor for oral candidiasis—advise rinsing mouth with water without swallowing after inhalation 1, 4

Patient and Family Education

Essential education components 1:

• Proper inhaler technique training
• Difference between "relievers" (bronchodilators) and "preventers" (controllers)
• Recognition of worsening asthma signs, especially nocturnal symptoms
• Written self-management plan with three elements: symptom/peak flow monitoring, prearranged action steps, and written guidance 1

Empower families to adjust treatment according to written plans rather than requiring consultation before changes 1

When to Consider Biologics

Biologics should ONLY be considered when asthma remains uncontrolled despite adherence to high-dose ICS and optimized standard therapy 5. Never prescribe biologics as first-line therapy or skip the ICS trial 5. Generic ICS formulations are the appropriate initial treatment 5.

Treatment Goals

Successful management achieves:

• Minimal daytime symptoms and no nighttime awakening 1
• No missed school/daycare 1
• Full participation in activities and sports 1
• Infrequent need for relief medications 1

Common Pitfalls to Avoid

Before stepping up therapy, verify:

• Age-appropriate inhaler device is being used 1
• Proper inhaler technique 1
• Medication adherence 1
• Parents understand management principles 1

Exclude alternative diagnoses in very young children (0-2 years): gastroesophageal reflux, cystic fibrosis, chronic lung disease of prematurity 1. Bronchodilator response is variable in the first year of life but should still be tried 1.