Treatment for Allergy-Induced Asthma in Pediatric Patients

Initial Assessment and Treatment Selection

The American Academy of Allergy, Asthma, and Immunology recommends initiation of long-term control therapy for children with persistent asthma symptoms, defined as more than 3 episodes of wheezing in the past year lasting more than 1 day and affecting sleep 1
Risk factors that should prompt treatment include either a parental history of asthma or physician-diagnosed atopic dermatitis, or two or more of the following: physician-diagnosed allergic rhinitis, peripheral blood eosinophilia, or wheezing apart from colds 1, 2

The American Academy of Pediatrics recommends low-dose inhaled corticosteroids via nebulizer, dry powder inhaler (DPI), or metered-dose inhaler (MDI) with holding chamber/face mask as first-line therapy 3, 4
Alternative therapies for children under 5 years include leukotriene receptor antagonists (LTRAs) such as montelukast, and cromolyn sodium 3, 2

The American Academy of Allergy, Asthma, and Immunology recommends low-dose inhaled corticosteroids as first-line therapy 3, 4
Alternative therapies for children 5-11 years include LTRAs (montelukast), cromolyn or nedocromil, and sustained-release theophylline 3, 2

The American Thoracic Society recommends daily low-dose ICS with as-needed short-acting beta-agonist (SABA), or as-needed ICS and SABA used concomitantly as first-line options 5
For moderate to severe persistent asthma, ICS-formoterol in a single inhaler as both daily controller and reliever therapy is recommended 5

The American Academy of Allergy, Asthma, and Immunology recommends assessing response to therapy within 4-6 weeks, and considering alternative therapies or diagnoses if clear benefit is not observed within this timeframe 1
Once control is established and sustained, a careful step-down in therapy should be attempted 1

For children with exercise-induced symptoms, adding a pre-exercise dose of SABA or using ICS-LABA combination therapy may be considered 6
For children with allergic asthma aged 5 years and older with controlled symptoms, subcutaneous immunotherapy (SCIT) may be considered as an adjunct treatment 6
For children with frequent exacerbations despite ICS therapy, step-up options include increasing ICS dose, adding LABA for children 4 years and older, or adding LTRA 4

Not all wheezing in young children is asthma; viral respiratory infections are the most common cause of wheezing in preschool-aged children 4
Underdiagnosis and undertreatment are key problems in young children with asthma, and early recognition and appropriate treatment of high-risk children may result in secondary prevention of childhood asthma and improved long-term outcomes 1, 4
When using ICS, titrate to the lowest effective dose to maintain control while minimizing potential side effects 4

For children under 4 years, two preferred options exist: (1) adding long-acting inhaled beta2-agonists to low-dose ICS, or (2) increasing the dose of ICS within the medium-dose range, with medium doses of ICS as monotherapy for moderate asthma representing a preferred treatment option in this age group, as increasing the dose is most effective in reducing asthma exacerbations 7, 8
Medium doses of ICS have been shown effective in treating moderate and severe asthma in infants and young children, with increasing the dose being most effective in reducing asthma exacerbations 7, 8
Alternative but not preferred options include adding either LTRA or theophylline (if serum concentrations are monitored) to low-to-medium doses of ICS 8

Strong evidence from clinical trials following children for up to 6 years suggests that the use of inhaled corticosteroids at recommended doses does not have long-term, clinically significant, or irreversible effects on vertical growth, bone mineral density, ocular toxicity, or suppression of adrenal/pituitary axis, according to the Journal of Allergy and Clinical Immunology 7, 8