In preschool children, asthma can be a diagnostic challenge. It should be considered in children with recurrent episodes of a cough, wheezing, chest tightness, or shortness of breath. These symptoms can vary in frequency and intensity over time. Early symptoms of an exacerbation may include:
Symptoms may be triggered by many factors, including upper respiratory tract infections, activity, stress and environmental exposure to allergens, and tobacco smoke to name a few.
In the 2017 update, the Global Initiative for Asthma (GINA) published guidelines for asthma management in children ages five years and younger. While medications are an important component of asthma management, it is important to remember that a multipronged approach to asthma management is comprised of a number of strategies, including education, skills training, clinical monitoring, and environmental control measures when necessary. The goals of asthma management include normal activity and good control of asthma symptoms, as well as minimizing future risk from exacerbations and medication side effects. Also, another goal is to maintain lung function and lung development as close to normal as possible.
The following section highlights a stepwise approach to asthma medications used for rescue and control in this age group. Step therapy is based on the domains of severity and control.
Stepwise Approach to Asthma Medication for Asthma in Children younger than five years
Step one for children with intermittent asthma is taking a quick relief medication such as albuterol. It should be available for rescue on an as needed basis. Albuterol is a short-acting beta-2 agonist. The preferred delivery is as an aerosol. Oral administration is not recommended because it has a slower onset of action and a higher rate of side effects as compared to the aerosol preparation. When given as an aerosol, albuterol provides relief of acute asthma symptoms in five to 15 minutes and lasts for approximately four to six hours. It should be noted that it is not effective in all children with wheezing.
Steps two through four describe controller treatment recommendations for children with persistent asthma. A short-acting beta-2 agonist should also be available for rescue as above.
In step two, a low-dose inhaled corticosteroid (ICS) is the preferred initial treatment to achieve asthma control. It should be given for at least two to three months to establish effectiveness. Spacer devices are available commercially and are recommended in this age group for use with metered dose inhalers. Alternative options include daily administration of a leukotriene receptor antagonist (LTRA), such as montelukast.
Step three is considered if asthma control is not achieved with three months of step two care, and an alternative diagnosis, inhaler technique, and adherence have been addressed. Doubling the initial low dose of ICS often works best. Based on data from use in older children the addition of a LTRA to low-dose ICS may be considered as an alternative to the increased dose of ICS.
Step four is recommended when a child fails to achieve good control on step three level of care. Step four care includes both the continuation of controller therapy and referral of the child to an asthma specialist for further evaluation and treatment recommendations. There is insufficient data on inhaled corticosteroids and long-acting beta-2 agonists combinations to recommend their use in this age group.
Children with asthma should be assessed at regular intervals. Adjustments to therapy (step up or step down) can be made as necessary. At each visit, medications should be reviewed for adherence, efficacy, and potential adverse effects. Also, children with seasonal asthma exacerbations may require further evaluation and treatment for allergies. Annual influenza immunization is an important consideration for all asthmatic children. The use of pulmonary function/spirometry test should is not recommended for checkups and/or diagnosis due to the greater potential for inaccurate readings.
Asthma Action Plans
Asthma action plans are developed by medical providers in partnership with parents. It is recommended that asthma action plans are written documents in which parents are provided with up-to-date instructions regarding symptom recognition, response when symptoms are identified, and steps to take in the case of an asthma emergency.
Asthma Medication Classes: Reliever Medications
Inhaled short-acting beta-2 agonists (SABA) (e.g., albuterol, levalbuterol) are the preferred and most commonly used options for quick relief of asthma symptoms and bronchoconstriction. Potential adverse effects include tremors, tachycardia, and palpitations. These adverse effects are seen more often during initial exposure. Tolerance will commonly occur.
Short-acting anticholinergics like ipratropium bromide are not recommended for routine use; however, they have shown benefit in combination with SABA during emergency department care of acute asthma exacerbations. Use of ipratropium is not FDA-approved for use in this age group but is referenced in the GINA guidelines. Dry mouth and bitter taste have been reported as possible adverse effects.
Asthma Medication Classes: Controller Medications
Inhaled Corticosteroids (ICS) are the preferred option for the initial management of mild persistent asthma and are a component of treatment plans for moderate and severe persistent asthma. Local side-effects may include dysphonia and oropharyngeal candidiasis. Use of a spacer device and having child rinse his or her mouth with water after using an ICS decreases the risk of oral thrush. High-dose corticosteroids are associated with systemic side effects, such as reduced growth velocity.
Combination therapy with an ICS plus long-acting beta-2 agonist (LABA) bronchodilator has been used in older children and adults with asthma. The combination of fluticasone propionate and salmeterol as a dry powder inhaler (diskus) has been evaluated for safety down to age four years. Efficacy data was extrapolated from patients ages 12 years and older. There is very limited data in children less than age four years. The aerosol preparation of Salmeterol and Fluticasone is FDA approved for ages 12 years and older. There is a boxed warning advising that long-acting beta-2 agonists such as salmeterol increase the risk of asthma-related death.
The leukotriene modifier, montelukast, is the only leukotriene modifier indicated for use in this age group and is available in either granules or chewable tablets depending on the age. It is an alternative option either alone or in combination with inhaled corticosteroids depending on the level of asthma severity and control. Safety and efficacy are not established for asthma in children younger than 12 months, although it is approved for use in allergic rhinitis for infants as young as six months of age. Systemic corticosteroids (tablet, suspension or intramuscular (IM) or intravenous (IV) injection) given for short term treatment, also known as burst therapy (usually given for three to five days) are important early in the treatment of severe acute exacerbations. In young children, the suspension is often better tolerated and accepted than tablets. Tapering is required if treatment is given for more than two weeks.
A pMDI with a valved holding chamber is the preferred delivery system. For children 0 to 5 years of age, a face mask is recommended over a mouthpiece. Different sized masks are available. A valved holding chamber allows for the medication to go to the lungs instead of impacting the back of the throat. It also helps with coordination of actuation.
A nebulizer device with either a face mask or a mouthpiece is an alternative method; however, not every medication is available as a nebulizer solution.
Asthma is a serious health and economic concern in the United States, costing $56 billion each year. The average cost to care for a child with asthma was $1039 in 2009. Asthma surveillance data from the CDC shows that one in 11 children have asthma, which equals seven million children. Uncontrolled asthma disrupts daily life and causes one in two children to miss at least one day of school. This averaged to about 10.5 million missed school days. In 2009, there were 479,300 asthma-related hospitalizations, 1.9 million asthma-related emergency department visits, and 8.9 million asthma-related doctor visits.