GINA Guidelines for Childhood Asthma Management
Core Treatment Philosophy
All children with asthma should receive inhaled corticosteroid (ICS)-containing controller therapy rather than short-acting beta-agonist (SABA) alone, as SABA-only treatment increases the risk of severe exacerbations and asthma-related mortality. 1, 2, 3
The primary goals prioritize complete symptom abolition, normal lung function restoration, prevention of severe attacks, enabling normal growth, and eliminating school absences. 4
Age-Specific Assessment of Asthma Control
Children 0-4 Years
Well-controlled asthma is defined by ALL of the following: 5
- Daytime symptoms ≤2 days/week
- Nighttime awakenings ≤1 time/month
- No interference with normal activity
- SABA use ≤2 days/week
- 0-1 exacerbations requiring oral corticosteroids per year
Not well-controlled when: 5
- Daytime symptoms >2 days/week
- Nighttime awakenings >1 time/month
- Some activity limitation
- SABA use >2 days/week
- 2-3 exacerbations per year
Very poorly controlled when: 5
- Symptoms throughout the day
- Nighttime awakenings >1 time/week
- Extreme activity limitation
- SABA use several times per day
3 exacerbations per year
Children 5-11 Years
Well-controlled asthma requires ALL of: 5
- Daytime symptoms ≤2 days/week (not more than once each day)
- Nighttime awakenings ≤1 time/month
- No interference with normal activity
- SABA use ≤2 days/week
- FEV₁ or peak flow >80% predicted/personal best
- FEV₁/FVC >80%
- 0-1 exacerbations per year
Not well-controlled when: 5
- Symptoms >2 days/week or multiple times on ≤2 days/week
- Nighttime awakenings ≥2 times/month
- Some activity limitation
- SABA use >2 days/week
- FEV₁ 60-80% predicted
- FEV₁/FVC 75-80%
Very poorly controlled when: 5
- Symptoms throughout the day
- Nighttime awakenings ≥2 times/week
- Extreme activity limitation
- SABA use several times per day
- FEV₁ <60% predicted
- FEV₁/FVC <75%
- ≥2 exacerbations per year
Stepwise Controller Therapy
Step 1: Mild Intermittent Asthma
For adults and adolescents (Track 1 preferred): As-needed low-dose ICS-formoterol combination is superior to SABA alone, reducing severe exacerbations by ≥60%. 1, 3
For children 5-11 years: Low-dose ICS is the preferred first-line controller therapy for persistent asthma. 6 Alternative options include leukotriene receptor antagonists (montelukast), cromolyn, or nedocromil, though these are less effective than ICS. 6
Step 2: Mild Persistent Asthma
Low-dose ICS delivered via metered-dose inhaler with spacer, dry powder inhaler, or nebulizer is the preferred therapy. 6
Step 3-4: Moderate Asthma
Step-up options when control is not achieved within 4-6 weeks: 6
- Add long-acting beta-agonist (LABA) to low-dose ICS, OR
- Increase ICS to medium-dose range, OR
- Add leukotriene receptor antagonist to ICS
Step 5: Severe Asthma
High-dose ICS plus LABA combinations, with consideration for oral corticosteroids, add-on long-acting muscarinic antagonists, azithromycin, or biologic therapies. 7, 1
Device Selection by Age
Ages 0-4 years: MDI with spacer and face mask is the appropriate delivery device. 4
Ages 5+ years: MDI with spacer or dry powder inhaler. 4 For 7-year-olds specifically, an MDI with large-volume spacer is preferred because most children this age cannot achieve adequate coordination with an unmodified MDI. 6
Critical pitfall: Never use an unmodified MDI without a spacer because lung deposition is poor and systemic absorption increases. 6
Acute Severe Asthma Management
Recognition of Severity
Acute severe features: 4
- Too breathless to talk or feed
- Respirations >50 breaths/min
- Pulse >140 beats/min
- Peak flow <50% predicted or best
Life-threatening features: 4
- Peak flow <33% predicted or best
- Poor respiratory effort
- Cyanosis, silent chest
- Fatigue/exhaustion
- Agitation or reduced consciousness
Immediate Treatment
Bronchodilator therapy: 6
- Nebulized salbutamol 5 mg (or 2.5 mg for children under 2 years) via oxygen-driven nebulizer
- Alternative: terbutaline 10 mg (half dose in very young children)
- Oral prednisolone 1-2 mg/kg daily (maximum 40 mg) is the preferred initial therapy for children who can tolerate oral medication.
- Duration: 1-5 days until control is established, no tapering needed
- Intravenous methylprednisolone (or hydrocortisone 200 mg every 6 hours) is reserved for children too ill to take oral medications or with life-threatening features
Corticosteroids must be administered immediately together with bronchodilator therapy; delaying steroid administration until after bronchodilator response provides no benefit. 6
Escalation for Life-Threatening Asthma
Intravenous aminophylline: 5 mg/kg over 20 minutes, followed by maintenance infusion of 1 mg/kg/hour. 6
Critical pitfall: Never omit the aminophylline loading dose without confirming theophylline use history, as giving a loading dose to a child already on oral theophyllines can cause toxicity. 6
Exercise-Induced Bronchoconstriction
Pretreat with albuterol 15 minutes before exercise to prevent exercise-induced bronchoconstriction. 6 Alternatively, a daily leukotriene receptor antagonist can be used as part of the controller regimen. 6
Encourage regular physical activity and implement a warm-up period before vigorous exercise to lessen severity. 6 Treat exercise-related bronchoconstriction rather than restricting activity. 6
Monitoring and Step-Down Criteria
At Every Visit
Verify inhaler technique at every visit; improper technique is the most common cause of apparent treatment failure. 6, 4
Document: 6
- Days of school missed
- Frequency of daytime and nighttime symptoms
- Frequency of rescue medication use
- Any activity limitation
Record height and weight velocities to monitor for potential growth suppression when high-dose ICS (>400 µg/day) are used. 6 Short-term reductions in tibial growth rate have been shown at doses greater than 400 µg/day, though low-dose regimens have minimal impact compared with the growth-delaying effect of uncontrolled asthma itself. 5, 6
Step-Down Criteria
Attempt step-down after benefits are sustained for 2-4 months, and reassess inhaler technique before stepping down. 6 Schedule regular follow-up every 3-6 months to reassess control and adjust therapy. 6
Self-Management and Education
Written Asthma Action Plan
All children with asthma should have a written asthma action plan developed with direct involvement of the child (when age-appropriate), addressing the child's concerns, preferences, and school schedule. 6, 3
The three essential elements are: 5
- Monitoring of symptoms, peak flow, and drug usage
- Taking prearranged action by the patient
- Written guidance for when to initiate or increase inhaled steroids, self-administer steroid tablets when peak flow falls below agreed levels or <60% of normal, and urgently seek medical attention when treatment is not working
School Medication Plan
Include a school medication administration plan to ensure the child has timely access to controller and rescue medication at school. 6
Treatment Outcomes and Goals
The outcome of successful management should be: 5
- Minimal symptoms during the day and no waking at night
- No missed playgroup, nursery, or school
- Full participation in activities and sports
- Relatively infrequent relief medication use
Common Pitfalls to Avoid
Antibiotics have no place in uncomplicated asthma management. 4 Antihistamines including ketotifen have proved disappointing in clinical practice. 4 Hyposensitization (immunotherapy) is not indicated in asthma management. 4
Routine home use of nebulizers should be avoided; an MDI with a large-volume spacer provides equivalent efficacy, is less costly, and reduces unnecessary nebulizer use. 6