How should asthma control and quality of life be assessed and managed in a child with persistent asthma?

Assessing and Managing Asthma Control and Quality of Life in Children with Persistent Asthma

Asthma control in children should be assessed at every clinical visit using age-specific criteria that evaluate both impairment (symptoms, rescue medication use, activity limitation, lung function) and risk (exacerbations, medication side effects), with management adjusted through a stepwise approach that prioritizes inhaled corticosteroids as the cornerstone of therapy.

Assessment Framework by Age Group

Children 0-4 Years

Well-controlled asthma is defined by:

• Symptoms ≤2 days/week 1
• Nighttime awakenings ≤1 time/month 1
• No interference with normal activity 1
• Short-acting β2-agonist use ≤2 days/week 1
• 0-1 exacerbations requiring oral corticosteroids per year 1

Not well-controlled criteria:

• Symptoms >2 days/week 1
• Nighttime awakenings >1 time/month 1
• Some activity limitation 1
• Short-acting β2-agonist use >2 days/week 1
• 2-3 exacerbations requiring oral corticosteroids per year 1

Children 5-11 Years

Well-controlled asthma requires:

• Symptoms ≤2 days/week but not more than once each day 1
• Nighttime awakenings ≤1 time/month 1
• No interference with normal activity 1
• Short-acting β2-agonist use ≤2 days/week 1
• FEV1 or peak flow >80% of predicted/personal best 1
• FEV1/FVC >80% 1
• 0-1 exacerbations requiring oral corticosteroids per year 1

The level of control is based on the most severe impairment or risk category—meaning if any single criterion falls into "not well-controlled," the overall assessment is not well-controlled. 1

Validated Assessment Tools

Self-Assessment Questionnaires

For children ≥12 years, validated questionnaires provide objective measurement:

• Asthma Control Test (ACT): Score ≥20 indicates well-controlled asthma; scores 16-19 suggest not well-controlled; scores ≤15 indicate very poorly controlled 1
• Asthma Control Questionnaire (ACQ): Score ≤0.75 indicates well-controlled; ≥1.5 indicates not well-controlled 1
• Asthma Therapy Assessment Questionnaire (ATAQ): Score 0 indicates well-controlled; 1-2 not well-controlled; 3-4 very poorly controlled 1

The ACT consists of 5 questions scored 1-5 regarding activity levels, frequency of daytime/nighttime symptoms, rescue inhaler use, and patient perception of control during the past 4 weeks. 1 A validation study showed 69.5% agreement between ACT scores and specialist assessment at a cutpoint of 20. 1

Important Limitations

One critical limitation is that existing instruments measure symptoms over the previous 4 weeks and do not incorporate long-term symptoms or activity limitations, potentially underestimating asthma's effect on children's lives. 1 Additionally, these tools may not accurately detect lifestyle adaptation—children who avoid physical activity to prevent symptoms may report falsely good control. 2

Different measures of asthma control frequently disagree with each other. 3 In one study of 71 children aged 4-11 years, clinical assessment by a pediatrician and the cACT agreed only 69% of the time, while FENO and cACT agreed only 49.3% of the time. 3

Quality of Life Assessment

Impact on Children

Uncontrolled asthma significantly impairs health-related quality of life in children, with lower physical summary scores (38.1 vs 49.8 for controlled asthma) and psychosocial scores (48.2 vs 53.8). 4

Children with uncontrolled asthma experience:

• More school absences (5.5 vs 2.2 days) 4
• Higher rates of arriving late or leaving early (26.7% vs 7.1%) 4
• More missed school-related activities (40.6% vs 6.2%) 4
• Greater rescue inhaler use at school (64.2% vs 31.0%) 4
• More frequent visits to the school nurse (22.5% vs 8.8%) 4

Beyond traditional outcomes, poorly controlled asthma increases risk of obesity, reduces daily physical activity and cardiovascular fitness, impairs concentration and focused attention, increases learning disabilities, and elevates risk of depression. 2 These effects require sustained improvement in control (>1 year) to reverse. 2

Impact on Caregivers

Caregivers of children with uncontrolled asthma report significantly greater work and activity impairment and lower quality of life for emotional, time-related, and family activities. 4

Management Algorithm

Initial Therapy Selection

For children 0-4 years with persistent asthma, initiate daily long-term control therapy if:

• ≥2 episodes of wheezing in the past year lasting >1 day that affected sleep AND high risk factors (parental asthma, atopic dermatitis, OR ≥2 of: food sensitization, ≥4% blood eosinophilia, wheezing apart from colds) 1
• Consistently requiring short-acting β2-agonist >2 days/week for >4 weeks 1
• Exacerbations requiring oral corticosteroids within 6 months 1

Inhaled corticosteroids are the preferred initial long-term control therapy for all age groups. 1 Alternative options for children 0-4 years include cromolyn or montelukast. 1

Stepwise Adjustment Based on Control

Step up therapy when:

• Asthma is not well-controlled after 2-4 weeks of current therapy with verified adherence and correct inhaler technique 1
• Rescue medication use increases to >2 days/week (excluding exercise prevention) 5

For children 4-5 years on low-dose inhaled corticosteroids (fluticasone ~125 µg twice daily) with frequent exacerbations, increase to medium-dose (fluticasone ~250 µg twice daily) as the first step-up option. 6 This approach avoids potential side effects of combination therapy in this age group. 6

If medium-dose ICS does not achieve control after 4-6 weeks, add montelukast to the existing regimen rather than escalating to high-dose ICS. 6 Montelukast is FDA-approved for children as young as 1 year. 6

For children ≥12 years, adding a long-acting β2-agonist to inhaled corticosteroids is the preferred Step 3 therapy when low-to-medium dose ICS alone is insufficient. 5 Combination therapy reduces mild exacerbations by 40% and severe exacerbations by 29% compared to higher-dose ICS alone. 5

Step Down Considerations

Once good asthma control is maintained for ≥3 consecutive months, attempt a step-down to the lowest effective dose. 6, 5 Children 0-4 years have high rates of spontaneous remission, making regular reassessment essential. 1

Critical Implementation Points

Before Any Therapy Escalation

Verify proper inhaler technique—including correct spacer use and mask fit—as incorrect technique is the most common cause of apparent treatment failure in young children. 6 Confirm adherence through pharmacy records and direct questioning. 1

Monitoring Schedule

Schedule follow-up visits:

• Every 1-6 weeks while gaining control 1
• Every 1-6 months once control is maintained (frequency depends on step of care) 1
• Every 3 months if step-down in therapy is anticipated 1

At every visit, assess asthma control, medication technique, written asthma action plan, patient adherence, and patient/caregiver concerns. 1

Objective Measurements

Obtain spirometry at least every 1-2 years, more frequently for not well-controlled asthma. 1 For children ≥5 years, lung function assessment is a required component of control evaluation. 1

Common Pitfalls

Physicians and patients often underestimate the level of asthma control. 1 Do not rely solely on patient/caregiver report—incorporate objective measures including lung function, school absences, and rescue medication use verified through pharmacy records. 1

Assessment over the 2-4 weeks between visits may miss longer-term patterns. 1 Include global assessment questions such as "Is your child's asthma better or worse since the last visit?" 1

Never use long-acting β2-agonists as monotherapy—they must always be combined with an inhaled corticosteroid. 5 Studies show significantly greater exacerbations and treatment failures when LABAs are used without ICS. 5