How should I manage a 7‑year‑old child with asthma, including stepwise therapy and an emergency action plan?

Management of Asthma in a 7-Year-Old Child

For a 7-year-old with persistent asthma, initiate low-dose inhaled corticosteroids (ICS) as first-line controller therapy, delivered via metered-dose inhaler with spacer, and develop a symptom-based written action plan that involves the child in decision-making. 1, 2

Initial Assessment and Controller Therapy Selection

Start with low-dose ICS as the cornerstone of treatment for any child with persistent asthma (defined as symptoms >2 days/week or nighttime awakenings). 1, 2 This age group (5-11 years) falls into a critical developmental window where proper asthma control prevents long-term lung growth impairment. 3

Delivery Device Selection

• Always use a metered-dose inhaler with large volume spacer for this age group—most 7-year-olds cannot achieve proper coordination for unmodified MDI use. 3, 2
• Verify and document proper inhaler technique at every visit, as poor technique is the most common cause of treatment failure. 1, 2
• Dry powder inhalers may be considered if the child demonstrates adequate inspiratory flow and technique. 1

Alternative Controllers (Less Preferred)

If ICS cannot be used or is ineffective after 4-6 weeks:

• Leukotriene receptor antagonists (montelukast) 1, 2
• Cromolyn or nedocromil 1
• These alternatives are consistently less effective than ICS and should only be second-line options. 1, 2

Stepwise Therapy Adjustment

Step-Up Criteria (if control not achieved in 4-6 weeks):

1. First option: Add long-acting beta-agonist (LABA) to low-dose ICS 1
2. Second option: Increase ICS to medium-dose range 1
3. Third option: Add leukotriene receptor antagonist to ICS 1

Step-Down Criteria:

• Attempt after benefits sustained for 2-4 months 1
• Always reassess and verify inhaler technique before stepping down—this prevents misattributing poor technique to inadequate medication. 1

Treatment Goals for This Age Group

The child should achieve:

• Minimal daytime symptoms and no nighttime awakening 3, 2
• No missed school days 3, 2
• Full participation in activities and sports without limitation 3, 2
• Infrequent need for rescue medication (≤2 days/week) 2
• Peak flow >75% predicted with diurnal variability <25% 2

Written Asthma Action Plan (Critical Component)

Develop a symptom-based written action plan rather than peak-flow based—symptom-based plans reduce acute care visits by 27% (NNT=9) and are preferred by children. 4

Essential Elements to Include:

• Involve the child directly in developing the plan and reviewing adherence—address the child's concerns, preferences, and school schedule. 3
• Daily controller medication instructions 5
• When and how to increase rescue medication (albuterol 2-4 puffs every 4 hours for worsening symptoms) 1, 2
• Clear triggers for seeking emergency care: inability to speak in full sentences, no improvement after rescue medication, severe breathing difficulty 2
• School medication administration plan 3

Key evidence: Symptom-based action plans are superior to peak-flow monitoring for preventing exacerbations, likely due to better adherence and earlier identification of deterioration. 4

Rescue Medication Protocol

• Albuterol (salbutamol) via MDI with spacer: 2-4 puffs every 4-6 hours as needed 1, 2
• For acute worsening at home: Can repeat every 2-4 hours, but failure to respond or early deterioration requires immediate medical assessment 3
• Avoid nebulizers for routine home use—they are overused, expensive, and can be effectively replaced by MDI with large volume spacer. 3, 2

Exercise-Induced Bronchoconstriction Management

If the child has symptoms with physical activity:

• Pretreatment with albuterol 15 minutes before exercise 3
• Alternative: Leukotriene receptor antagonist as daily controller 3
• Promote physical activity—treat the exercise-induced symptoms rather than limiting activity. 3
• Warm-up period before vigorous exercise 3

Acute Exacerbation Management (For Parents/Caregivers)

Home Management:

1. Albuterol 4-6 puffs via spacer immediately 1, 2
2. Repeat every 20 minutes for up to 3 doses 1
3. Start oral prednisolone 1-2 mg/kg (maximum 40 mg) if no improvement 1

Seek Emergency Care If:

• No improvement after 3 albuterol treatments 2
• Difficulty speaking or walking 2
• Lips or fingernails turning blue 2
• Respiratory rate >50 breaths/minute or heart rate >140 beats/minute 2

Monitoring and Follow-Up

At Each Visit, Document:

• Days of school missed since last visit 3
• Frequency of daytime and nighttime symptoms 3
• Frequency of rescue medication use 3
• Activity limitation 3
• Height and weight velocities—monitor for growth suppression with ICS >400 mcg/day, though asthma itself delays growth more than low-dose ICS. 3

Common Pitfalls to Avoid:

• Never assume proper inhaler technique—verify at every visit, as this is the most common cause of apparent treatment failure. 1, 2
• Don't use unmodified MDI without spacer—lung deposition is poor and systemic absorption increases. 3, 2
• Don't delay stepping up therapy if control is inadequate after 4-6 weeks of verified adherence and proper technique. 1
• Don't continue high-dose ICS indefinitely—attempt step-down after 2-4 months of good control. 1

Special Consideration for This Age Group

Monitor for disease progression and loss of lung growth—while treatment won't alter underlying disease progression, stepping up therapy may be required to maintain control as the child grows. 3 Regular follow-up every 3-6 months is essential to adjust therapy and ensure continued adequate control. 3