What are the current treatment guidelines for childhood asthma?

Current Treatment Guidelines for Childhood Asthma

Childhood asthma management follows a stepwise approach prioritizing inhaled corticosteroids as the foundation of controller therapy, with the goal of achieving minimal symptoms, no nighttime awakening, full participation in activities, and minimal need for rescue medications. 1

Goals of Asthma Management

The primary objectives prioritize morbidity and quality of life outcomes 1:

• Abolish symptoms completely during day and night 2, 1
• Enable full participation in activities and sports without restriction 2, 1
• Eliminate school absences due to asthma 2, 1
• Minimize need for relief medications 2, 1
• Maintain peak expiratory flow ≥80% of predicted or personal best 2
• Ensure normal growth and development 1

Stepwise Pharmacologic Treatment Approach

Step 1: Intermittent Asthma

• Short-acting beta2-agonists (albuterol/salbutamol) as needed for symptom relief 2, 3
• No daily controller medication required 3

Step 2: Mild Persistent Asthma

For children ≥5 years:

• Low-dose inhaled corticosteroids (fluticasone 100 mcg or budesonide equivalent) as preferred first-line controller therapy 4, 3
• Alternative: Leukotriene receptor antagonists, though less commonly used 5

For children <5 years:

• Low-dose inhaled corticosteroids via nebulizer, DPI, or MDI with holding chamber (with or without face mask) 4
• For children 12 months to 8 years: budesonide inhalation suspension 0.25-0.5 mg once daily or divided twice daily 6

Step 3: Moderate Persistent Asthma

• Increase inhaled corticosteroid dose to medium range 2, 3
• Consider adding long-acting beta2-agonist (LABA) in children ≥4 years, but never use LABA as monotherapy 7, 3
• Alternative add-on options: leukotriene antagonists, theophylline 3

Step 4: Severe Persistent Asthma

• High-dose inhaled corticosteroids plus LABA combination 2, 3
• Consider additional controller: leukotriene antagonist or theophylline 3
• May require oral corticosteroids for exacerbations 2

Age-Appropriate Medication Delivery Devices

Proper device selection is critical for treatment success 1:

• Ages 0-4 years: MDI with spacer and face mask 1, 4
• Ages 5+ years: MDI with spacer or dry powder inhaler 1, 4
• Most children cannot use unmodified MDI without spacer device 8
• Nebulizers are appropriate for very young children or acute exacerbations 2, 6

Inhaled Corticosteroid Dosing Considerations

Use the lowest dose that provides acceptable symptom control 2:

• Short-term reductions in tibial growth rate occur at doses >400 mcg/day, but long-term effects remain unclear 2
• Asthma itself delays growth and puberty, with eventual catch-up growth 2, 1
• Monitor height and weight velocities regularly 2, 1

Management of Acute Exacerbations

For acute severe asthma exacerbations 8, 1:

• Administer systemic corticosteroids immediately (oral prednisolone 1-2 mg/kg, maximum 40-60 mg) 8
• High-dose short-acting beta2-agonists: 4-8 puffs via MDI with spacer every 20 minutes for 3 doses, or nebulized salbutamol 2.5-5 mg 8
• Add ipratropium bromide 100 mcg when initial beta-agonist treatment fails 8
• High-flow oxygen to maintain saturation >92% 8

Indications for systemic corticosteroids in exacerbations 2:

• Symptoms and PEF progressively worsen day by day
• PEF falls below 60% of patient's best
• Sleep disturbed by asthma
• Morning symptoms persist until midday
• Diminishing response to inhaled bronchodilators

Patient and Family Education Requirements

Education is essential and the responsibility of the physician 2, 1:

• Training in proper inhaler technique with demonstration and verification 1, 4
• Understanding difference between "relievers" (bronchodilators) and "preventers" (anti-inflammatory medications) 2, 1
• Recognition of worsening asthma signs, especially nocturnal symptoms 2, 1
• Written action plan detailing when to increase medications and when to seek care 2, 8, 1
• Peak flow monitoring for children ≥5 years 2, 1

Environmental Control and Trigger Avoidance

General practitioners are best positioned to modify environmental triggers 2, 1:

• Maternal smoking is one of the most important modifiable triggers 2, 1
• Identify and minimize exposure to allergens (pets, dust, pollens, feathers) 2
• Avoid cigarette smoke exposure 2
• Manage emotional disturbances and family stress 2

Monitoring and Follow-Up

Regular assessment of treatment outcomes 2, 1:

• Days off school from asthma 2, 1
• Frequency of daytime and nighttime symptoms 1, 4
• Activity limitations and exercise tolerance 1, 4
• Frequency of relief medication use 1, 4
• Verify inhaler technique is correct at each visit 2
• Ensure family understands when and how to vary medications 2, 1
• Document height and weight velocities 2, 1

Critical Pitfalls to Avoid

Common management errors that worsen outcomes 2, 1:

• Antibiotics have no place in uncomplicated asthma management 2, 1
• Antihistamines including ketotifen have proved disappointing in clinical practice 2, 1
• Hyposensitization (immunotherapy) is not indicated for asthma management 2, 1
• Never use LABA as monotherapy—always combine with inhaled corticosteroids 7
• Ensure compliance with anti-inflammatory treatment before escalating therapy 2
• Verify proper inhaler technique before concluding treatment failure 2

Special Considerations for Very Young Children (0-2 Years)

Diagnosis and management are particularly challenging in this age group 2, 1:

• Recurrent wheeze often associated with viral infections without family history of atopy 2, 1
• Diagnosis relies almost entirely on symptom patterns, not objective testing 2, 1
• Bronchodilator response is variable in first year of life but should still be tried 2
• Consider other disorders that mimic asthma: gastroesophageal reflux, cystic fibrosis, chronic lung disease of prematurity 2