asthma

Stepwise Approach for Managing Infants and Young Children (5 Years of Age and Younger) With Acute or Chronic Asthma

Is your child meeting the goals of the updated asthma guidelines?

• Minimal or no chronic symptoms day or night
• Minimal or no exacerbations
• No limitations on activities; no school/work/parent's work missed
• Minimal use of short-acting inhaled beta 2 -agonist (< 1x per day, < 1 canister/month)
• Minimal or no adverse effects from medications
  
  

If not, he may need a step up in his treatment regimen. For help, first classify your child's asthma severity based on the symptoms he is having, either during the day or at night. Next, review the preferred daily medications. If your child isn't on a preferred treatment and he is not doing well, you may want to see your Pediatrician to talk about changing his treatment plan.

Step 4 - Severe Persistent

• Continual daytime symptoms or frequent nighttime symptoms
• Preferred daily medications:
  • High-dose inhaled corticosteroids AND Long-acting inhaled beta 2 -agonists AND, if needed, Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed
    60 mg per day). (Make repeat attempts to reduce systemic corticosteroids and
    maintain control with high-dose inhaled corticosteroids.)

Step 3 - Moderate Persistent

• Daily daytime symptoms or symptoms more than 1 night a week
• Preferred daily medications:
  • Low-dose inhaled corticosteroids and long-acting inhaled beta 2 -agonists OR Medium-dose inhaled corticosteroids.
• Alternative treatment:
  • Low-dose inhaled corticosteroids and either leukotriene receptor antagonist or
    theophylline.
• If needed (particularly in patients with recurring severe exacerbations):
  • Preferred treatment: Medium-dose inhaled corticosteroids and long-acting beta 2 -agonists.
  • Alternative treatment: Medium-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline.

Step 2 - Mild Persistent

• Daytime symptoms more than twice a week but less than once a day or symptoms more than 2 nights a month
• Preferred daily medications:
  • Low-dose inhaled corticosteroid (with nebulizer or MDI with holding chamber with or without face mask or DPI).
• Alternative treatment:
  • Cromolyn (nebulizer is preferred or MDI with holding chamber) OR leukotriene receptor antagonist.

Step 1 - Mild Intermittent

• Daytime symptoms less than or equal to 2 days a week and less than or equal to 2 nights a month
• No daily medications needed
  
  

Quick Relief (All Patients)

• Bronchodilator as needed for symptoms. Intensity of treatment will depend upon severity of exacerbation.
  • Preferred treatment: Short-acting inhaled beta2 -agonists by nebulizer or face mask and space/holding chamber
  • Alternative treatment: Oral beta 2 -agonist
• With viral respiratory infection
  • Bronchodilator q 4–6 hours up to 24 hours (longer with physician consult); in general, repeat no more than
  • Consider systemic corticosteroid if exacerbation is severe or patient has history of previous severe exacerbations
    
• Use of short-acting beta 2 -agonists >2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term control therapy.

Step Down

• Review treatment every 1 to 6 months; a gradual stepwise reduction in treatment may be possible

Step Up

• If control is not maintained, consider step up. First, review patient medication technique, adherence, and environmental control.

Notes

• The stepwise approach is intended to assist, not replace, the clinical decisionmaking required to meet individual patient needs.
• Classify severity: assign patient to most severe step in which any feature occurs.
• There are very few studies on asthma therapy for infants.
• Gain control as quickly as possible (a course of short systemic corticosteroids may be required); then step down to the least medication necessary to maintain control.
• Provide parent education on asthma management and controlling environmental factors that make asthma worse (e.g., allergies and irritants).
  
• Consultation with an asthma specialist is recommended for patients with moderate or severe persistent asthma. Consider consultation for patients with mild persistent asthma.
  
  

Next page > Asthma Guidelines for Children and Adults

NIH Publication No. 02-5075 July 2002

*Updates the NAEPP Expert Panel Report 2 (NIH Publication No. 97-4051).

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