Asthma Management in Children

Initial Assessment and Classification

The American Academy of Allergy, Asthma, and Immunology recommends determining asthma severity before initiating treatment, with mild persistent asthma characterized by symptoms >2 days/week but not daily, nighttime awakenings 3-4 times/month, and minor limitation with normal activities 1
The American Academy of Allergy, Asthma, and Immunology defines moderate persistent asthma as daily symptoms, nighttime awakenings >1 time/week but not nightly, and some limitation with normal activities 1

The American Academy of Pediatrics recommends low-dose inhaled corticosteroids via metered-dose inhaler (MDI) with spacer or dry powder inhaler as the preferred first-line therapy for children ≥5 years of age 1, 2, 3
The American Academy of Allergy, Asthma, and Immunology states that inhaled corticosteroids improve lung function, reduce hyperresponsiveness, decrease symptom scores, reduce oral corticosteroid courses, and prevent urgent care visits or hospitalizations compared to as-needed beta-agonists alone 1, 2
The American Thoracic Society notes that inhaled corticosteroids are more effective than cromolyn, nedocromil, theophylline, or leukotriene receptor antagonists for improving asthma outcomes 1, 2, 3

The National Asthma Education and Prevention Program recommends adding a long-acting beta-agonist (LABA) as a fixed-dose combination with an inhaled corticosteroid for children ≥4 years of age 2
The American Academy of Allergy, Asthma, and Immunology states that fluticasone monotherapy gains 42 additional asthma control days per year compared to montelukast, with a number needed to treat of approximately 6.5 4

The American Academy of Pediatrics recommends administering albuterol 4-8 puffs via MDI with spacer every 20 minutes for up to 3 doses, and starting oral prednisone 1-2 mg/kg (maximum 40 mg) immediately for home management of acute exacerbations 5, 6
The American College of Allergy, Asthma, and Immunology states that oxygen via nasal cannula or mask should be used to maintain SpO2 >90-92% in the office or emergency department 6, 5

The American Academy of Pediatrics notes that growth over 48 weeks is not statistically different between low-dose fluticasone, fluticasone/salmeterol combination, and montelukast, and recommends monitoring growth in all children on inhaled corticosteroids 4
The American Thoracic Society recommends using the lowest effective inhaled corticosteroid dose to maintain control, as benefits of asthma control outweigh small transient growth effects 1, 2

Diagnosis in very young children relies primarily on symptoms rather than objective lung function tests, and alternative diagnoses such as gastro-oesophageal reflux, cystic fibrosis, or chronic lung disease of prematurity should be considered 7
Bronchodilator response is variable in the first year of life, but bronchodilators should still be tried 7

Always use a large volume spacer device with metered-dose inhalers to enhance lung deposition and reduce oral side effects, as most children cannot achieve proper coordination for unmodified MDI use 7
Ensure the child is using an age-appropriate inhaler device and that inhaler technique is correct before stepping up therapy 7

Use large volume spacer devices with all MDI-delivered ICS to reduce oral candidiasis risk 7
Monitor for Candida albicans infection of the mouth and pharynx periodically, and advise patients to rinse mouth with water without swallowing after ICS inhalation 7
Short-term reductions in tibial growth rate occur with ICS doses >400 mcg/day, but these cannot be extrapolated to long-term effects, and growth should be monitored in all children on inhaled corticosteroids 7