Pediatric Asthma Management

Chronic Asthma Management

The American Thoracic Society recommends inhaled corticosteroids as the preferred first-line daily controller therapy for children with persistent asthma, across all pediatric age groups 1
For children with persistent asthma, the goal is to achieve minimal daytime symptoms and no nocturnal awakening, with full participation in activities and sports, and infrequent need for relief medications, as recommended by the Thorax guidelines 1
The Thorax guidelines suggest using the lowest inhaled corticosteroid dose that provides acceptable symptom control, to minimize side effects 1
Short-term reductions in growth rate can occur at inhaled corticosteroid doses above 400 µg/day, but long-term effects are unclear, according to the Thorax guidelines 1

The Praxis Medical Insights guidelines recommend immediate identification of children requiring aggressive treatment, based on clinical features such as severe respiratory distress, and administration of systemic corticosteroids without delay 3
The Praxis Medical Insights guidelines suggest that MDI with large volume spacer is equally effective to nebulization and may result in lower admission rates with fewer cardiovascular side effects, for acute asthma exacerbations 3, 2
High-flow oxygen via face mask should be administered to maintain SaO₂ >92%, as recommended by the Praxis Medical Insights guidelines 3, 4
Salbutamol (albuterol) should be administered via nebulizer or MDI with spacer, with repeat doses every 20 minutes for up to 3 doses in the first hour, according to the Praxis Medical Insights guidelines 3, 2
Systemic corticosteroids, such as oral prednisolone or IV hydrocortisone, should be administered immediately for acute severe asthma, as recommended by the Praxis Medical Insights guidelines 3, 4
Ipratropium bromide can be added to nebulizer treatment for acute asthma exacerbations, repeated every 6 hours, according to the Praxis Medical Insights guidelines 3, 4

Peak expiratory flow measurement should be repeated 15-30 minutes after starting treatment, and continuous pulse oximetry should be maintained with a target >92%, as recommended by the Praxis Medical Insights guidelines 3, 4
Response to treatment in the emergency department is a better predictor of hospitalization need than initial severity, according to the Praxis Medical Insights guidelines 3

Children should be admitted to hospital if they have persistent features of severe asthma after initial treatment, or if peak expiratory flow remains <50% predicted 15-30 minutes after treatment, as recommended by the Praxis Medical Insights guidelines 3, 4

Children can be discharged when they have been on discharge medication for 24 hours with proper inhaler technique verified, and peak flow is >75% of predicted with diurnal variability <25%, according to the Praxis Medical Insights guidelines 3, 4

For very young children (0-2 years), diagnosis of asthma relies almost entirely on symptoms rather than objective lung function tests, and other disorders may mimic asthma, such as gastroesophageal reflux or cystic fibrosis, as noted in the Thorax guidelines 1
Underestimating severity is a critical pitfall in assessing acute symptoms in infants, and any concerning features should prompt aggressive treatment, according to the Praxis Medical Insights guidelines 2

Antibiotics, aggressive hydration, methylxanthines, chest physiotherapy, mucolytics, and sedation should be avoided in pediatric asthma exacerbations, unless bacterial infection is confirmed, as recommended by the Praxis Medical Insights and Thorax guidelines 3, 1