What is the recommended treatment for a child with asthma?

Asthma Treatment in Children

For children aged 4 years and older with asthma, low-dose inhaled corticosteroids (ICS) via metered-dose inhaler with spacer or dry powder inhaler should be the first-line controller therapy, with step-up to combination ICS/long-acting beta-agonist (LABA) therapy if symptoms remain uncontrolled. 1

Initial Controller Therapy Selection

Children ≥5 Years of Age

• Start with low-dose inhaled corticosteroids as the preferred first-line controller medication 1
• Fluticasone propionate 100 mcg twice daily via Diskus or equivalent ICS dose is appropriate for most children 1, 2
• ICS therapy improves lung function, reduces airway hyperresponsiveness, decreases symptom scores, reduces oral corticosteroid courses, and prevents urgent care visits or hospitalizations compared to as-needed beta-agonists alone 1
• ICS are more effective than cromolyn, nedocromil, theophylline, or leukotriene receptor antagonists for improving asthma outcomes 1

Children 4-11 Years of Age

• Use fluticasone propionate 100 mcg twice daily or equivalent low-dose ICS 1
• Always use a large volume spacer device with metered-dose inhalers to enhance lung deposition and reduce oral side effects 3, 4
• Most children cannot achieve proper coordination for unmodified MDI use 3, 4

Very Young Children (0-2 Years)

• Diagnosis relies primarily on symptoms rather than objective lung function tests 3
• Bronchodilator response is variable in the first year of life, but bronchodilators should still be tried 3
• Consider alternative diagnoses such as gastro-oesophageal reflux, cystic fibrosis, or chronic lung disease of prematurity 3

Step-Up Therapy for Inadequate Control

When to Escalate Treatment

Before stepping up therapy, ensure: 3

• The child is using an age-appropriate inhaler device
• Inhaler technique is correct
• Parents understand management principles
• Adherence to current therapy is adequate

Preferred Step-Up Strategy

• Add a long-acting beta-agonist (LABA) as fixed-dose combination with ICS for children ≥4 years with uncontrolled symptoms 1
• Salmeterol 50 mcg/fluticasone 100 mcg twice daily is the recommended combination for children 4-11 years 1, 5
• Adding LABA to low-dose ICS is superior to doubling the ICS dose 6, 7

Evidence Supporting LABA Addition Over ICS Dose Doubling

• Children receiving salmeterol/fluticasone 50/100 mcg experienced 8.7% more symptom-free days and 8.0% more days without rescue medication compared to fluticasone 200 mcg alone 6
• Morning peak expiratory flow improved by 30.4 L/min with combination therapy versus 16.7 L/min with doubled ICS dose 6
• Good asthma control was maintained for 3.4 weeks with combination therapy versus 2.7 weeks with doubled ICS dose 6
• Fluticasone monotherapy gains only 42 additional asthma control days per year compared to montelukast, with a number needed to treat of approximately 6.5 1

Acute Exacerbation Management

Home Management of Acute Symptoms

• Administer albuterol 4-8 puffs via MDI with spacer every 20 minutes for up to 3 doses 1, 4
• Start oral prednisone 1-2 mg/kg (maximum 40-60 mg) immediately 1, 4
• Relief treatment can be repeated every 2-4 hours, but failure to respond or early deterioration requires immediate medical assessment 3, 4

Emergency Department/Office Management

• Administer high-flow oxygen via face mask to maintain SpO2 >90-92% 1, 4
• Give nebulized salbutamol 2.5 mg (age ≤2 years) or 5.0 mg (age >2 years) every 20 minutes for 3 doses, or alternatively 4-8 puffs via MDI with spacer 4
• Add ipratropium bromide 100 mcg to nebulizer when initial albuterol treatment fails or for severe exacerbations 4
• The combination of beta-agonist plus ipratropium reduces hospitalizations, particularly in patients with severe airflow obstruction 4

Systemic Corticosteroid Dosing

• Oral corticosteroids are preferred when the child can swallow and has no vomiting 4
• Prednisolone or prednisone 1-2 mg/kg/day (maximum 60 mg/day) in 2 divided doses 4
• Intravenous hydrocortisone 200 mg every 6 hours (or 4 mg/kg/dose every 6 hours) is reserved for children who are vomiting, seriously ill, or unable to take oral medications 4

Growth Monitoring and Safety Considerations

Inhaled Corticosteroid Effects on Growth

• Short-term reductions in tibial growth rate occur with ICS doses >400 mcg/day, but these cannot be extrapolated to long-term effects 3
• Growth over 48 weeks is not statistically different between low-dose fluticasone, fluticasone/salmeterol combination, and montelukast 1
• Monitor growth in all children on inhaled corticosteroids and use the lowest effective dose to maintain control 1
• The benefits of asthma control outweigh small transient growth effects 1

Other Safety Considerations

• Use large volume spacer devices with all MDI-delivered ICS to reduce oral candidiasis risk 3, 5
• Advise patients to rinse mouth with water without swallowing after ICS inhalation 5
• Monitor for Candida albicans infection of the mouth and pharynx periodically 5

Critical Pitfalls to Avoid

• Never use LABA monotherapy without concurrent ICS, as this increases the risk of serious asthma-related events 5
• Do not use unmodified MDI without spacer unless certain about the child's technique 3, 4
• Nebulizers are overused and may often be replaced by large volume spacer devices, which are equally effective with lower admission rates and fewer cardiovascular side effects 3, 4
• Do not delay systemic corticosteroids while giving repeated albuterol doses alone in acute exacerbations 4
• Underuse of corticosteroids is a leading cause of preventable asthma mortality 4
• Do not use antibiotics routinely in asthma exacerbations unless bacterial infection is confirmed 4

Stepwise Management Algorithm

Step 1: Low-dose ICS (fluticasone 100 mcg twice daily or equivalent) 1

Step 2: Add LABA to low-dose ICS (salmeterol 50 mcg/fluticasone 100 mcg twice daily) for children ≥4 years with persistent symptoms 1, 6

Step 3: Increase to medium-dose ICS/LABA combination (fluticasone 250 mcg/salmeterol 50 mcg twice daily) if needed 5

Rescue medication: Albuterol 2-4 puffs via MDI with spacer as needed for symptoms 1, 4