Children under 5 yrs

Summary of Stepwise Management in Children under 5yrs

Step 1: Mild intermittent asthma

Inhaled short-acting beta-2 agonist as required

Step 2: Regular preventer therapy

• Add inhaled steroid 200-400 mcg/day of BDP or equivalent, higher nominal doses may be required if drug delivery is difficult.
• Or leukotriene receptor antagonist if inhaled steroid cannot be used.
• Start at dose of inhaled steroid appropriate to severity of disease.

Step 3: Add-on therapy

• In children aged 2-5 years consider trial of leukotriene receptor antagonist.
• In children under 2 years consider proceeding to Step 4.

Step 4: Persistent Poor Control

Refer to respiratory paediatrician

Step 1: Mild intermittent asthma

Prescribe an inhaled short-acting beta 2 agonist as short-term reliever therapy for all patients with symptomatic asthma.

Patients with high usage of inhaled short-acting beta2 agonists should have their asthma management reviewed.

Step 2: introduction of regular preventer therapy

Inhaled steroids are the recommended preventer drug for adults and children for achieving overall treatment goals.

Inhaled steroids should be prescribed for patients with recent exacerbations, nocturnal asthma, impaired lung function or using inhaled beta2 agonists more than once a day.

Starting dose of inhaled steroids

Start patients at a dose of inhaled steroids appropriate to the severity of disease.

A reasonable starting dose will usually be 200 mcg per day. In children under 5 years, higher doses may be required if there are problems in obtaining consistent drug delivery.

Titrate the dose of inhaled steroid to the lowest dose at which effective control of asthma is maintained

Frequency of dosing of inhaled steroids

Give inhaled steroids initially twice daily.

Once a day inhaled steroids at the same total daily dose can be considered if good control is established.

Safety of Inhaled Steroids

Monitor children's height on a regular basis.

Consider the possibility of adrenal insufficiency in any child maintained on inhaled steroids presenting with a decreased level of consciousness; blood glucose levels should be checked urgently. Consider whether intramuscular (IM) hydrocortisone is required.

OTHER PREVENTER THERAPIES

Inhaled steroids are the first choice preventer drug. Alternative, less effective preventer therapies in patients taking short-acting beta2 agonists alone are:

• Leukotriene receptor antagonists have some beneficial clinical effect (and an effect on eosinophilic inflammation) Evidence level 1++
• Theophyllines have some beneficial effect (side-effects are more common and monitoring of plasma levels is required). Evidence level 1+
• Long-acting inhaled beta2 agonists have some beneficial effects but they are not recommended as first line preventer therapy. Evidence level 1+
• Antihistamines and ketotifen are ineffective. Evidence level 1++

Step 3: add-on therapy

CRITERIA FOR INTRODUCTION OF ADD-ON THERAPY

Carry out a trial of other treatments before increasing the inhaled steroid dose above 400 mcg/day in children.

Add-on therapy

If asthma control remains sub-optimal in children taking inhaled steroids at a dose of 400 mcg/day then Leukotriene receptor antagonists provide improvement in lung function, a decrease in exacerbations, and an improvement in symptoms. Evidence level 1+

Stepping down

Stepping down therapy once asthma is controlled is recommended, but often not implemented leaving some patients over-treated. There is little evidence regarding the most appropriate way to step down treatment.

Regular review of patients as treatment is stepped down is important. When deciding which drug to step down first and at what rate, the severity of asthma, the side-effects of the treatment, the beneficial effect achieved, and the patient's preference should all be taken into account.

Patients should be maintained at the lowest possible dose of inhaled steroid. Reduction in inhaled steroid dose should be slow as patients deteriorate at different rates. Reductions should be considered every three months, decreasing the dose by approximately 25-50% each time.

Specific management problems

EXERCISE-INDUCED ASTHMA

For most patients, exercise-induced asthma is an expression of poorly controlled asthma and regular treatment including inhaled steroids should be reviewed.

There is no evidence for medicines giving protection or not against exercise-induced asthma in children under 5 yrs.

Immediately prior to exercise, inhaled short-acting beta2 agonists are the drug of choice.