Management of Asthma in Children

Classification and Initial Assessment

Children with mild persistent asthma show symptoms more than twice weekly but less than daily, with occasional exacerbations that may affect activity 3
Children with moderate persistent asthma have daily symptoms, require daily medication, and experience exacerbations that affect activity 3
Severity assessment should include evaluation of daytime symptoms, nighttime awakenings, activity limitation, and lung function when age-appropriate 3

The American Academy of Allergy, Asthma, and Immunology recommends low-dose inhaled corticosteroids as the preferred therapy for mild persistent asthma in children 5 years and older 1, 3
Alternative therapies for children 5 years and older with mild persistent asthma include leukotriene receptor antagonists, cromolyn, or nedocromil 1, 2
For moderate persistent asthma in children 5 years and older, options include adding a long-acting beta2-agonist to low-dose ICS or increasing ICS dose to the medium-dose range 2, 3
For children under 5 years, low-dose inhaled corticosteroids are the preferred therapy, delivered via nebulizer, dry powder inhaler, or metered-dose inhaler with holding chamber 2, 3
Alternative therapies for children under 5 years include cromolyn or leukotriene receptor antagonists, such as montelukast 2, 4

Strong evidence shows that inhaled corticosteroids improve long-term outcomes compared to as-needed beta2-agonists, including reduced airway hyperresponsiveness, improved symptom scores, fewer courses of oral corticosteroids, and fewer urgent care visits and hospitalizations 1
Studies comparing ICS to cromolyn, nedocromil, theophylline, or leukotriene receptor antagonists show that none of these alternatives are as effective as ICS in improving asthma outcomes 1, 2

For children whose asthma is not well controlled on low-dose ICS, options include adding a long-acting beta2-agonist to low-dose ICS or increasing ICS dose to medium range 2, 3
Less preferred options include adding a leukotriene receptor antagonist or theophylline to low-medium dose ICS 2, 3

Monitor response to therapy carefully, especially in young children, and attempt to step down therapy if benefits are sustained for 2-4 months 3, 4
If no clear benefits within 4-6 weeks, consider stopping treatment and exploring alternative therapies or diagnoses 3, 4
Assess inhaler technique regularly to ensure proper medication delivery 5, 6

Viral respiratory infections are the most common trigger for asthma symptoms in young children 3
The decision to start long-term control therapy in very young children should weigh the risks of inadequately controlled asthma against potential medication side effects 4
For children with recurrent wheezing and positive asthma predictive index, early intervention with ICS may reduce morbidity 4

Undertreatment is a key problem in pediatric asthma management, and inadequate control can lead to permanent airway changes 3
Growth concerns with ICS are minimal at recommended doses and are outweighed by benefits of asthma control 4
Theophylline is not recommended for young children with mild persistent asthma due to risk of adverse effects, particularly during febrile illnesses 4