Asthma Management in Children

Recommended Delivery Methods

• Children as young as birth (0 years) can use spacer inhalers with a face mask, while children 4 years and older can typically use spacer inhalers with a mouthpiece, according to the American Academy of Allergy, Asthma, and Immunology 1
• The American Thoracic Society recommends that children 4 years and older use a spacer or Valved Holding Chamber (VHC) with a mouthpiece 1, 2
• Children under 4 years old may not be able to generate sufficient inspiratory flow for dry powder inhalers or coordinate breathing with MDI activation, and may have less difficulty with face mask with nebulizer or MDI with valved holding chamber (spacer) 1
• Children ≥4 years should use a spacer or valved holding chamber with proper technique to ensure optimal medication delivery, as recommended by the American College of Allergy, Asthma, and Immunology 1

Inhaler Technique

• Children should use slow, deep inhalation (30 L/min or 3-5 seconds) followed by a 10-second breath hold immediately after actuation, as recommended by the American Academy of Allergy, Asthma, and Immunology 1
• Actuate only once into spacer/VHC per inhalation, and when using large volume spacers, actuate the MDI, breathe in one puff, repeat the actuation, then breathe in the second puff, according to the American Thoracic Society 1, 2
• Proper technique for inhaler use in children ≥4 years includes using a spacer or valved holding chamber, ensuring a proper seal between the face mask and the child's face, and rinsing the mouth after administration to prevent oral thrush 3, 2

Spacer Maintenance

• Rinse plastic VHCs once a month with a low concentration of liquid household dishwashing detergent (1:5000 or a few drops per cup of water) and let air dry, as recommended by the American Academy of Allergy, Asthma, and Immunology 1

Alternative Delivery Methods

• Nebulizers are often overused and can be replaced by large volume spacer devices in many cases, according to the American Thoracic Society 2
• Every child given inhaled steroids from an MDI should use a large volume spacer to enhance deposition of medication in the lungs and reduce side effects, as recommended by the American Thoracic Society 2

Asthma Diagnosis and Treatment

• Asthma diagnosis in young children relies almost entirely on symptoms rather than objective lung function tests, as stated by the American Thoracic Society and European Respiratory Society 2
• Recurrent wheeze and cough in preschool-age children are often associated with viral respiratory infections, according to the American Thoracic Society and European Respiratory Society 2
• Other disorders, including gastro-esophageal reflux, cystic fibrosis, and chronic lung disease of prematurity, may mimic asthma in young children, as noted by the American Thoracic Society and European Respiratory Society 2

• Inhaled corticosteroids (ICS) are recommended as the initial treatment for asthma in pediatric patients, with options to step up to combination therapy as needed, and dose definitions for ICS as follows:

  Age	Low Dose	Medium Dose	High Dose
  4-11 years	88-176 mcg/day	176-352 mcg/day	>352 mcg/day
  ≥12 years	88-264 mcg/day	264-440 mcg/day	>440 mcg/day

• The NAEPP guidelines recommend a stepwise approach to asthma management, including the use of fluticasone for asthma severity management, with the following steps:

  Step	Asthma Severity	Recommended Treatment
  1	Intermittent	Short-acting beta-agonists as needed
  2	Mild persistent	Low-dose inhaled corticosteroid (fluticasone 88-264 mcg/day)
  3	Moderate persistent	Low-dose fluticasone plus long-acting beta-agonist OR medium-dose fluticasone (264-440 mcg/day)
  4	Moderate-severe persistent	Medium-dose fluticasone plus long-acting beta-agonist
  5-6	Severe persistent	High-dose fluticasone (>440 mcg/day) plus long-acting beta-agonist with or without additional medications [4]

Monitoring and Adjusting Treatment

• Evaluate response to therapy in 4-6 weeks, and monitor height regularly, as ICS therapy may be associated with a small, non-progressive effect on growth velocity (approximately 1 cm) 1
• Consider stepping down therapy once control is achieved and maintained for 3 months, using "the lowest dose of ICS that maintains asthma control" as recommended by the EPR-3 guidelines 1
• Close monitoring of response to therapy is recommended, with consideration of stopping treatment if no clear benefit is seen within 4-6 weeks 1
• Assess efficacy within 4-6 weeks of starting treatment, and consider step-down therapy once adequate control is maintained for at least 3 months, as recommended by the NAEPP guidelines and American Academy of Family Physicians 4
• Regular growth monitoring is recommended for children using inhaled corticosteroids, as advised by the Journal of Allergy and Clinical Immunology 5

Potential Side Effects and Considerations

• Local effects of fluticasone include oral candidiasis, nasal irritation, epistaxis, pharyngitis, and cough, as reported by the American Academy of Otolaryngology-Head and Neck Surgery 6
• Systemic effects, such as growth suppression in children, particularly with high doses, and adrenal suppression with doses >750 mcg daily, can occur, as noted by the Journal of Allergy and Clinical Immunology and Gastroenterology society 7, 5
• Short-term reductions in tibial growth rate have been observed with inhaled steroids at doses greater than 400 μg/day in young children with asthma, although long-term effects are unclear 2