Asthma Management in Children 5 Years and Younger

Primary Controller Options

The American Academy of Allergy, Asthma, and Immunology recommends low-dose inhaled corticosteroids (ICS) as the preferred and safest controller medication for children 5 years and younger with persistent asthma, with budesonide nebulizer solution FDA-approved from age 1 year and fluticasone dry powder inhaler approved from age 4 years 1, 2
ICS represent the most effective anti-inflammatory treatment and should be the initial controller medication for persistent asthma in young children, according to the American Academy of Pediatrics 3, 2
Budesonide nebulizer solution is FDA-approved for children 1-8 years of age and is the preferred formulation for children under 4 years who cannot effectively use other devices, as recommended by the American Academy of Allergy, Asthma, and Immunology 1, 2
Fluticasone dry powder inhaler (DPI) is FDA-approved for children 4 years and older, as approved by the FDA 1, 4
Delivery should use either a nebulizer or metered-dose inhaler (MDI) with a valved holding chamber (spacer), with or without a face mask for children under 4 years, as recommended by the American Academy of Pediatrics 1, 3

The benefits of ICS clearly outweigh concerns about potential adverse effects, including the small, nonprogressive reduction in growth velocity, according to the American Academy of Allergy, Asthma, and Immunology 1, 2
ICS should be titrated to the lowest effective dose needed to maintain asthma control, as recommended by the American Academy of Pediatrics 1
Mouth rinsing after each treatment reduces local side effects, as recommended by the American Dental Association 6, 5

Montelukast 4 mg chewable tablet is FDA-approved for children 2-6 years of age, as approved by the FDA 6, 2
Consider LTRAs when inhaled medication delivery is suboptimal due to poor technique or adherence issues, as recommended by the American Academy of Allergy, Asthma, and Immunology 6, 2
LTRAs are listed as alternative (not preferred) therapy because evidence for efficacy is less robust than for ICS, according to the American Academy of Pediatrics 3, 6

Salmeterol DPI is FDA-approved only for children 4 years and older, as approved by the FDA 6, 2
LABAs should never be used as monotherapy and only in combination with ICS for moderate-to-severe asthma, as recommended by the American Thoracic Society 7
No evidence supports ICS-formoterol as single maintenance and reliever therapy (SMART) in children under 5 years, according to the American Academy of Allergy, Asthma, and Immunology 8

Start daily long-term controller therapy in children 5 years and younger who have symptoms requiring treatment more than 2 times per week, or severe exacerbations requiring beta-agonist more frequently than every 4 hours over 24 hours, as recommended by the American Academy of Pediatrics 1, 6
Assess response within 4-6 weeks of initiating therapy, and stop treatment if no clear beneficial effect is obvious within 4-6 weeks, as recommended by the American Academy of Allergy, Asthma, and Immunology 6, 2, 5

Do not overtreat viral-induced wheeze that resolves between episodes, as recommended by the American Academy of Pediatrics 1
Do not use high-dose ICS initially, and start with low doses and titrate up only if needed, as recommended by the American Academy of Allergy, Asthma, and Immunology 1, 5
Do not prescribe LABAs as monotherapy, and ensure proper inhaler technique, as recommended by the American Thoracic Society 7, 6, 5