The management of chronic asthma in infants and young children (≤ 5 years of age) involves a stepwise approach tailored to the severity and control of symptoms. This approach emphasizes achieving symptom control, minimizing exacerbations, and using the least amount of medication necessary to maintain control. Below is the stepwise outline based on Global Initiative for Asthma (GINA) 2024 guidelines.
Stepwise Approach for Managing Chronic Asthma in Young Children (≤ 5 Years)
1. Assess Severity and Control
- Key factors to assess:
- Frequency and intensity of symptoms (daytime and nighttime).
- Limitation of activities.
- Frequency of exacerbations requiring systemic corticosteroids.
- Use of reliever medication.
- Risk factors for exacerbations (e.g., history of severe episodes, exposure to allergens, smoke).
Step 1: For Infrequent Symptoms
- Indication:
- Symptoms < 2 days/week.
- No nighttime symptoms or limitation of activities.
- Management:
- As-needed low-dose inhaled corticosteroid (ICS)–formoterol:
- Preferred for symptom relief and exacerbation prevention.
- Alternatively: Short-acting beta-agonist (SABA) as needed.
Step 2: For Frequent or Mild Persistent Symptoms
- Indication:
- Symptoms > 2 days/week but not daily.
- Exacerbations requiring oral corticosteroids at least once a year.
- Management:
- Daily low-dose ICS (e.g., budesonide, fluticasone) + SABA as needed.
- Alternatives:
- Leukotriene receptor antagonist (LTRA) (e.g., montelukast) if ICS is not feasible.
- As-needed ICS-formoterol.
Step 3: For Moderate Persistent Symptoms
- Indication:
- Daily symptoms or waking due to asthma at least once a week.
- Management:
- Daily low-dose ICS + long-acting beta-agonist (LABA) or LTRA.
- Alternatively:
- Medium-dose ICS if LABA is not feasible.
- Continue as-needed ICS-formoterol or SABA for symptom relief.
Step 4: For Severe Persistent Symptoms
- Indication:
- Symptoms most days or waking ≥ 1 night/week despite Step 3 treatment.
- Management:
- Daily medium-dose ICS + LABA or LTRA.
- Consider referral to a specialist for:
- High-dose ICS + additional controller (e.g., LTRA).
- Oral corticosteroids for severe, refractory cases (shortest duration).
Step 5: For Uncontrolled Asthma Despite Step 4
- Indication:
- Persistent symptoms or frequent exacerbations despite Step 4 treatment.
- Management:
- Specialist consultation required.
- Options include:
- High-dose ICS + LABA.
- Add-on therapies (e.g., biologics like omalizumab in children ≥ 6 years if allergic asthma is suspected).
- Trial of daily oral corticosteroids (minimize due to long-term side effects).
Key Components of Asthma Management
1. Asthma Education
- Teach proper inhaler technique.
- Develop and review an asthma action plan.
- Educate caregivers on recognizing symptoms of exacerbation.
2. Environmental Control
- Reduce exposure to allergens (e.g., dust mites, mold, pet dander).
- Avoid tobacco smoke and air pollutants.
3. Monitoring
- Frequent follow-ups to assess symptom control and medication adherence.
- Adjust treatment stepwise based on control level:
- Step up: If symptoms persist despite adherence.
- Step down: If well-controlled for at least 3 months.
4. Managing Exacerbations
- Use SABA or ICS-formoterol for acute symptoms.
- Initiate short courses of systemic corticosteroids for severe exacerbations.
Stepwise Dosing Guide for Common Medications
- Low-dose ICS:
- Budesonide: 200–400 mcg/day (via nebulizer or inhaler).
- Fluticasone: 100–200 mcg/day.
- Medium-dose ICS:
- Budesonide: 400–800 mcg/day.
- Fluticasone: 200–400 mcg/day.
- LTRA:
- Montelukast: 4 mg daily for children 6 months to 5 years.
Key Considerations
- Infants: Symptoms may overlap with viral wheezing; diagnose asthma cautiously. Trial ICS for 2–3 months may help confirm.
- Medication Delivery: Use age-appropriate devices (e.g., spacers with masks for inhalers, nebulizers).
- Regularly reassess to differentiate between viral-induced wheezing and persistent asthma.
