Asthma Management: 0-4 Years of Age

ASTHMA MANAGEMENT: 0−4 YEARS OF AGE
Classifying Asthma Severity and Initiating Treatment
Assessing severity and initiating therapy in children who
are not currently taking long-term control medication
Components of Severity Classification of Asthma Severity
(≥12 Years of Age)
Intermittent Persistent
Mild Moderate Severe
Impairment Symptoms ≤2 days/week >2 days/week but not daily Daily Throughout the day
Nighttime awakenings 0 1−2×/month 3−4×/month >1×/week
Short-acting β2-agonist use for symptom control (not prevention of EIB) ≤2 days/week >2 days/week but not daily Daily Several times per day
Interference with
normal activity
None Minor limitation Some limitation Extremely limited
Risk Exacerbations requiring oral systemic corticosteroids 0−1/year ≥2 exacerbations in 6 months requiring oral systemic corticosteroids, OR ≥4 wheezing episodes/1 year lasting >1 day AND risk factors for persistent asthma
• Consider severity and interval since last exacerbation
• Frequency and severity may fluctuate over time
• Exacerbations of any severity may occur in patients in any severity category
Recommended Step
for Initiating Treatment
Step 1 Step 2 Step 3 and consider short course of oral systemic corticosteroids
In 2−6 weeks, depending on severity, evaluate level of asthma control that is achieved. If no clear benefit is observed in 4−6 weeks, consider adjusting therapy or alternative diagnoses.
Stepwise Approach for Managing Asthma
Intermittent
Asthma
Persistent Asthma: Daily Medication
Consult with asthma specialist if Step 3 care or higher is required.
Consider consultation at Step 2.

 
Step up if
needed

(first, check
adherence, inhaler
technique, and
environmental
control)
————————
Assess
control

————————
Step down if
possible

(and asthma is
well controlled
at least
3 months)
 
  Step 6
Preferred:
High-dose ICS +
either LABA or
Montelukast
and
Oral systemic
corticosteroids
  Step 5
Preferred:
High-dose ICS +
either LABA or
Montelukast
  Step 4
Preferred:
Medium-dose
ICS + either
LABA or
Montelukast
  Step 3
Preferred:
Medium-dose ICS
  Step 2
Preferred:
Low-dose ICS
Alternative:
Cromolyn or
Montelukast
 
 
 
Step 1
Preferred:
SABA PRN*
Patient Education and Environmental Control at Each Step

Quick-Relief Medication for All Patients

• SABA as needed for symptoms. Intensity of treatment depends on severity of symptoms

• With viral respiratory infection: SABA every 4−6hrs up to 24hrs (longer with physician consult). Consider short course of oral systemic corticosteroids if exacerbation is severe or patient has history of previous severe exacerbations

• Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations on initiating daily long-term-control therapy

Assessing Asthma Control and Adjusting Therapy
Components of Control Classification of Asthma Control
Well Controlled Not Well Controlled Very Poorly Controlled
Impairment Symptoms ≤2 days/week >2 days/week Throughout the day
Nighttime awakenings ≤1×/month >1×/month >1×/week
Interference with normal activity None Some limitation Extremely limited
Short-acting β2-agonist use for symptom control (not prevention of EIB) ≤2 days/week >2 days/week Several times per day
Risk Exacerbations requiring oral systemic corticosteroids 0−1/year 2−3/year >3/year
Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Recommended Action
for Treatment

• Maintain current treatment

• Regular follow-up every 1−6 months

• Consider step down if well controlled for at least 3 months

• Step up—1 step—and

• Reevaluate in 2−6 weeks

• If no clear benefit in 4−6 weeks, consider alternative diagnoses or adjusting therapy

• For side effects, consider alternative treatment options

• Consider short course of oral systemic corticosteroids

• Step up—1−2 steps—and

• Reevaluate in 2wks

• If no clear benefit in
4−6 weeks, consider alternative diagnoses or adjusting therapy

• For side effects, consider alternative treatment options

NOTES

Key: EIB = exercise-induced bronchospasm; ICS = inhaled corticosteroid; LABA = inhaled long-acting β2‑agonist; SABA = inhaled short-acting β2‑agonist.

*Preferred therapy is based on Expert Panel Report 2 from 1997.

REFERENCES

Adapted from National Asthma Education and Prevention Program. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma 2007.
U.S. Department of Health and Human Services. Available at: http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed on: November 26, 2012.

(Rev. 7/2016)

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