Asthma treatment in children::
ASTHMA TREATMENT OVERVIEW — The optimal treatment of asthma depends upon a number of factors, including the child’s age and the severity and frequency of asthma attacks. For most children, asthma treatment can control symptoms, allowing the child to participate fully in activities and sports.
Successful treatment of asthma involves three components:
- Controlling and avoiding asthma triggers
- Regularly monitoring asthma symptoms and lung function
- Understanding how to use medications to treat asthma
This article discusses the treatment of asthma in children younger than 12 years. Children with asthma who are 12 years and older are treated with medications and doses similar to that of adults.
Separate articles discuss the symptoms and diagnosis of asthma and use of asthma dose inhalers in children. (See “Patient information: Asthma symptoms and diagnosis in children” and “Patient information: Asthma inhaler techniques in children” and “Patient information: Trigger avoidance in asthma”.)
A number of topics about asthma in adults are also available. (See “Patient information: Asthma treatment in adolescents and adults” and “Patient information: How to use a peak flow meter” and “Patient information: Asthma inhaler techniques in adults” and “Patient information: Asthma and pregnancy”.)
CONTROLLING ASTHMA TRIGGERS — The factors that set off or worsen asthma symptoms are called triggers. Identifying and avoiding asthma triggers are essential in preventing asthma flare-ups. Trigger avoidance is discussed in detail in a separate article. (See “Patient information: Trigger avoidance in asthma”.)
Common asthma triggers generally fall into several categories:
- Allergens (including dust, pollens, and furred animals)
- Respiratory infections
- Irritants (such as tobacco smoke, aerosol sprays, some cleaning products)
After identifying potential asthma triggers, the parent and healthcare provider should develop a plan to deal with the triggers. If possible, the child should completely avoid or limit exposure to the trigger (eg, eliminate exposure to cigarette smoke, remove carpets from bedrooms, not allow pets to sleep in the child’s room). Children who have persistent problems despite efforts to avoid triggers may benefit from seeing an asthma specialist.
Exercise is an exception to the general rule about trigger avoidance. Exercise is encouraged for children with asthma. An asthma action plan should include steps to prevent and treat exercise-related symptoms. (See ‘Exercise-induced asthma’ below.)
MONITORING ASTHMA SYMPTOMS AND LUNG FUNCTION — Successful management of asthma requires the parent and/or child to monitor their asthma regularly. This is primarily done by recording the frequency and severity of asthma symptoms (coughing, shortness of breath, and wheezing).
In addition, a healthcare provider may recommend that the child measure his or her lung function with a test known as a peak flow (peak expiratory flow rate [PEFR]). Routine follow-up appointments with a healthcare provider are recommended to review asthma symptom control and treatment plans.
Asthma diary — A healthcare provider may recommend keeping a daily asthma diary when symptoms are not well controlled or when starting a new treatment. In the diary, the child’s peak flow readings, asthma symptoms (eg, coughing, wheezing), and medications are recorded (figure 1).
A periodic diary may be recommended for children who have stable symptoms and whose medications have not changed recently. This type of diary can be completed before visiting the healthcare provider and helps the parent/child and healthcare provider to determine if the asthma treatment plan needs to be adjusted (figure 2).
An alternative to these diaries is the Asthma Control Test (figure 3).
Peak expiratory flow rate — Peak expiratory flow rate (PEFR) measures the rate at which a person can exhale. This rate depends upon the degree of airway narrowing. PEFR monitoring can provide data that can be used to make treatment decisions. Children five years of age and older are usually capable of performing peak flow measurements. This is discussed in greater detail elsewhere. (See “Patient information: How to use a peak flow meter”.)
Review of asthma treatment — Children with asthma usually see a healthcare provider every one to six months to monitor the child’s symptom severity and frequency and response to treatment. If control has been adequate for at least three months, the asthma medication dose may be decreased. If control is not adequate, the medication schedule, delivery technique, and trigger avoidance will be reviewed, and the medication dose may be increased.
CATEGORIES OF ASTHMA SYMPTOMS — The medications used to treat asthma in children vary according to a child’s age, the severity of asthma, and the level of asthma symptom control. A child’s asthma treatment plan must be monitored and adjusted on a regular basis. If symptoms are well controlled, medication can often be reduced. As symptoms worsen, medication adherence and delivery techniques should be assessed. If these are adequate, medication should be increased.
Intermittent asthma — A child is defined as having intermittent asthma if he or she has asthma with minimal symptoms and infrequent asthma flares. Specifically, children with intermittent asthma have the following characteristics:
- Symptoms of asthma occur two or fewer times per week
- Asthma does not interfere with daily activities
- Awakenings during the night due to asthma symptoms occur two or fewer times per month
- Asthma flares require oral glucocorticoids (also called corticosteroids or steroids) no more than once per year
A child with asthma symptoms that are triggered only during vigorous exercise (exercise-induced bronchoconstriction) might fit into this category, even if the child exercises more than twice per week. However, symptoms during exercise may also indicate that the child’s asthma is poorly controlled. (See “Patient information: Exercise-induced asthma”.)
Persistent asthma — Children with persistent asthma have symptoms regularly. There may be days when activities are limited due to asthma symptoms, and the child may be awakened from sleep. Lung function is usually normal between episodes, but becomes abnormal during an asthma attack. Persistent asthma can be mild, moderate, or severe.
The criteria that are used to determine a child’s asthma severity include the number of days per week that a child has one or more of the following:
- Symptoms such as cough, wheeze, and shortness of breath
- Awakenings during the night due to cough or wheeze
- Use of a bronchodilator (reliever medication)
- Symptoms that affect the child’s ability to participate in normal activities
The number of flares per year that require treatment with oral glucocorticoids (also called corticosteroids or steroids) are also taken into consideration when determining asthma severity.
Consultation with an asthma specialist (a pulmonologist or allergist) is recommended for children who have moderate or severe persistent asthma, as well as those ages zero to four years who have any form of persistent asthma.
QUICK-RELIEF MEDICATIONS FOR ASTHMA
Bronchodilators — Short-acting bronchodilators (also called beta-2 agonists) relieve asthma symptoms rapidly, by relaxing the muscles around narrowed airways. In the United States, albuterol (Ventolin®, Proventil®, ProAir®, and others) is the most commonly used short-acting bronchodilator. These medications are sometimes referred to as “quick-acting relievers”. Children with intermittent asthma, the mildest form of asthma, will require these symptom-relieving medications only occasionally.
There is no benefit to using short-acting bronchodilators on a regular basis and there may be some harm. If asthma symptoms are occurring more than twice per week on a regular basis, the child should be evaluated by a healthcare provider. Other medications are more effective for persistent symptoms in this situation.
Metered-dose inhaler versus nebulizer — Short-acting bronchodilators can be delivered with a nebulizer or through a metered-dose inhaler with an attached spacer (valved holding device) device and an infant- or child-sized mask. (See “Delivery of inhaled medication in children”.)
- Nebulizers use compressed air to change a medication from liquid form to a fine spray that can be inhaled through a mask or mouthpiece (picture 1). When a facemask is used, it should be placed snugly over the face; moving the mask just 1 centimeter away from the face reduces the dose of an inhaled medication by up to 50 percent. Nebulizers may be preferred to metered-dose inhalers for children who are unable to use a handheld device. (See “Use of medication nebulizers in children”.)
- Metered-dose inhalers dispense liquid or fine powder medications, which mix with the air that is breathed into the lungs. The spacer and face mask help to ensure that the greatest amount of medication is delivered to the lungs (picture 1). It is preferable to have the child use the inhaler when he or she is awake and not crying. (See “Patient information: Asthma inhaler techniques in children”.)
Side effects of bronchodilators — Some children feel shaky, have an increased heart rate, or become hyperactive after using a short-acting bronchodilator. Using a single puff of the inhaler may reduce these side effects and only minimally decrease the inhaler’s benefit, but this should be discussed with the child’s healthcare provider. The side effects often decrease over time.
CONTROLLER MEDICATIONS FOR ASTHMA — Children with persistent asthma need to take medication on a daily basis to keep their asthma under control, even if there are no symptoms of active asthma on a given day. Medications taken daily for asthma are called “long-term controller” medicines and function to decrease inflammation (or swelling) of the small airways over time. (See “Chronic asthma in children younger than 12 years: Controller medications”.)
Some controller medicines are delivered by inhaler, while others are taken as a pill or liquid. The doses and types of controller medications prescribed to children with asthma depend on a child’s asthma severity and level of symptom control.
Inhaled glucocorticoids — Inhaled glucocorticoids work by reducing swelling and sensitivity of the bronchial tubes, thereby reducing their exaggerated reaction to asthma triggers. These medications are the preferred treatment for persistent asthma. Regular treatment with an inhaled glucocorticoid medication can reduce the frequency of symptoms (and the need for inhaled bronchodilators), improve quality of life, and decrease the risk of a serious asthma attack.
Inhaled glucocorticoids may be taken by metered dose inhaler with a valved holding chamber (spacer) or by nebulizer. Chambers are available with different sized masks to fit younger children. These medications need to be taken on a daily basis to effectively control asthma symptoms. An inhaled bronchodilator is still used as needed to relieve symptoms and before exposure to asthma triggers. (See “Patient information: Asthma inhaler techniques in children”.)
Side effects of glucocorticoids — Unlike glucocorticoids that are taken by mouth, very little of the inhaled glucocorticoid is absorbed into the bloodstream, and there are few side effects. As the dose of inhaled glucocorticoids is increased, more of the medication is absorbed into the bloodstream, and the risk of side effects increases.
The most common side effect of low-dose inhaled glucocorticoids is oral candidiasis (thrush). This can usually be prevented by taking inhaled glucocorticoids with a spacer with or without a face mask (which helps to deliver medication to the lungs rather than the mouth). The child should rinse his or her mouth or brush teeth and tongue immediately after inhalation. A hoarse voice and sore throat (without thrush) are less common side effects that are usually managed by changing to a different glucocorticoid preparation.
The most common side effect from long-term use of moderate or high-dose inhaled glucocorticoids is temporary slowing of growth; the body adjusts to a normal growth rate within the first year of use. Other rare but possible side effects include cataracts, increased pressure in the eye (glaucoma), and increased bone loss (osteoporosis).
Although the side effects of glucocorticoids are of concern to many parents, it is important to remember that untreated asthma itself can prevent the child from participating in activities, influence the way a child perceives his or her well-being, and place the child at risk for an asthma exacerbation.
In addition, the risk of side effects is far less with inhaled glucocorticoids than with oral glucocorticoids (eg, prednisolone). The goal of treatment is to use the lowest possible dose while maintaining good asthma control and minimizing the risk of serious asthma attacks. This usually means that treatment will be adjusted frequently, depending upon how well symptoms are controlled.
Leukotriene modifiers — A category of medications called leukotriene modifiers are sometimes used as an alternative to low-dose inhaled glucocorticoids in children who have mild persistent asthma. However, leukotriene modifiers are not quite as effective as inhaled glucocorticoids. The leukotriene modifier montelukast (Singulair®) is taken by mouth once daily and is available as a chewable pill or granules that can be taken directly or mixed into certain soft foods.
Leukotriene modifiers can be used to prevent asthma symptoms before exposure to a trigger or before exercising. They may also be used in addition to inhaled glucocorticoids in children who have more severe and/or difficult-to-control asthma.
There are worries that montelukast might be linked to an increase in side effects like mood changes and aggressive behavior. Parents should notify the child’s healthcare provider if any changes in mood or behavior occur after starting this medication.
Long-acting bronchodilators — Long-acting bronchodilators (also called long-acting beta agonists, or LABA) are bronchodilators that have a longer-lasting effect (at least 12 hours) compared with the short-acting beta agonists that are used as reliever medications (see ‘Quick-relief medications for asthma’ above).
These medications (LABA) are used as add-on therapy in children who have more severe and/or difficult-to-control asthma. They should be used only in combination with an inhaled glucocorticoid; they should not be used alone, because there are concerns that using LABA long-term can cause severe asthma episodes. An attempt should be made to taper off the medication that contains a LABA once the child’s asthma is under control.
Cromolyn — Cromolyn (Intal®) may be recommended as an alternative to low-dose inhaled glucocorticoids for children with mild persistent asthma. This medicine is not a glucocorticoid and works by decreasing the activity of allergy cells. It is taken via metered-dose inhaler, dry powder inhaler, or by nebulization (availability of these formulations varies from one country to another; most formulations are no longer available in the United States). Cromolyn is generally less effective than inhaled glucocorticoids. It is also less convenient, as it must be taken three or four times per day. Cromolyn can be used to prevent asthma symptoms before exposure to a trigger or before exercising.
EXERCISE-INDUCED ASTHMA — An article that discusses exercise-induced asthma is available separately. If exercise is a trigger for asthma, the child can take an extra dose of bronchodilator medication, leukotriene modifier, or cromolyn before exercise. The child should not use more than twice the amount of medication normally used. (See “Patient information: Exercise-induced asthma”.)
ASTHMA ATTACK TREATMENT — The term “asthma attack” is somewhat confusing because it does not distinguish between a mild increase in symptoms and a life-threatening episode. Asthma symptoms may be aggravated by changes in air quality, the common cold, and new or continued exposure to triggers. These triggers can cause mild, moderate, or severe asthma symptoms to develop. Any of these changes could be considered an asthma “attack.”
Some children will have periodic, mild asthma attacks that never require emergency care, while others may have severe and sudden asthma attacks that require a call for emergency medical attention.
Asthma action plan — The child and/or parent will work with their healthcare provider to develop tailored guidelines (also called an action plan) to follow when symptoms increase. Asthma action plans are available for children up to age five (figure 4), for children five and older and adults (figure 5), and for school (figure 6A-C).
Asthma symptoms are divided into three zones, which are assigned colors similar to those of a traffic light. These zones can be used to make decisions about the need for treatment:
Green — Green signals that the lungs are functioning well. When asthma symptoms are not present or are well controlled, patients should continue their regular medicines and activities.
Yellow — Yellow is a sign that the airways in the lungs are somewhat narrowed, making it difficult to move air in and out; this occurs when there is an increase in asthma symptom frequency or severity. A short-term change or increase in medication is generally required. Patients should change or increase their asthma medication according to the plan that was discussed with their provider.
Red — Red is a sign that the airways are significantly narrowed and requires immediate treatment; this occurs with a significant increase in asthma symptoms. The quick-acting reliever inhaler should be used according to the plan discussed with the provider and the child should be evaluated by a medical professional.
Emergency care plan — Parents should work with their child’s healthcare provider to formulate an emergency care plan that explains specifically what to do if asthma symptoms worsen. This may include more frequent use of a reliever medication.
However, if asthma symptoms worsen or do not improve after use of a quick-acting reliever medication, the parent should immediately call for emergency medical assistance. Severe asthma attacks can be fatal if not treated promptly.
In most areas of the United States, emergency medical assistance is available by calling 911. Parents should not attempt to drive to the hospital and should not ask someone else to drive. Calling 911 is safer than driving for two reasons:
- From the moment EMS personnel arrive, they can begin evaluating and treating asthma. If a parent drives to the hospital, treatment cannot begin until the child arrives at the emergency department.
- If a dangerous complication of asthma occurs on the way to the hospital, EMS personnel may be able to treat the problem immediately.
Following an asthma attack, most children are given a 3- to 10-day course of an oral glucocorticoid medication (eg, prednisone, prednisolone). This treatment helps to decrease the swelling and mucus production in the lungs and reduces the risk of a second asthma attack.
Wear medical identification — Many children with medical conditions wear a bracelet, necklace, or similar alert tag at all times. If an accident occurs and the child cannot explain his or her condition, this will help responders provide appropriate care