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Asthma - Management
Children under 5 years of age with uncontrolled symptoms on current treatment: How do I manage?

  • Adjust treatment using the step-wise approach outlined below.
  • Before starting a new drug or stepping up treatment, confirm with the parents their understanding of the role of treatment, adherence to treatment, inhaler technique, and appropriate elimination of trigger factors.
  • Choose an effective delivery system on the basis of convenience, cost, and suitability:
    • Step 1: Prescribe a short-acting beta2-agonist to all children, for rapid symptom relief.
    • Step 2: Consider starting an inhaled corticosteroid (ICS) at a dose that is appropriate for the severity of symptoms (usually equivalent to beclometasone CFC-free as Clenil Modulite® 200 to 400 micrograms/day). Indications for ICS include:
      • Having symptoms three times weekly or more, or
      • Awakening with symptoms one night weekly or more, or
      • Having an exacerbation in the last 2 years, or
      • Using inhaled short-acting beta2-agonist three times weekly or more.
    • If ICS are not tolerated or are contraindicated, consider starting a leukotriene receptor antagonist at step 2 (but do so only in children aged 2–5 years).
    • Step 3: If the child still has symptoms while using regular ICS (equivalent to Clenil Modulite® [beclometasone CFC-free] 400 micrograms/day), consider:
      • For children younger than 2 years: Move to step 4.
      • For children aged 2–5 years: Initiating a trial of a leukotriene receptor antagonist; if asthma remains inadequately controlled, move to step 4.
    • Step 4: Refer to a paediatrician with knowledge about respiratory diseases.
  • Offer self-management education, including written action plans focusing on the child's and the family's needs.
Clarification / Additional information
  • Inhaled corticosteroids should be used twice a day, at the lowest dose that maintains effective control of asthma. Higher doses may be needed in young children to ensure adequate drug delivery.
  • Leukotriene receptor antagonists: montelukast is the only drug in this class that is licensed for use in children 2–5 years of age.
  • Choose an effective delivery system on the basis of availability, the child's ability to use the device, convenience, and cost. For details, see Delivery system for children under 5 years.
Basis for recommendation
  • These recommendations are based on the British Guideline on the Management of Asthma: a national clinical guideline [SIGN and BTS, 2009]:
    • Evidence is limited for all types of treatment for asthma in children younger than 5 years compared with older children and adults.
    • Inhaled corticosteroids (ICS): the evidence now suggests that ICS are safe and effective in younger children. These agents are beneficial even in mild asthma, but there is no benefit in starting treatment at very high doses and then stepping down. Concerns remain about the adverse effects of ICS in children.

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