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Official reprint from UpToDate


www.uptodate.com 2016 UpToDate

Asthma in children younger than 12 years: Initiating therapy and monitoring control

Authors Section Editors Deputy Editor


Gregory Sawicki, MD, MPH Robert A Wood, MD Elizabeth TePas, MD, MS
Kenan Haver, MD Gregory Redding, MD

Contributor disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2016. | This topic last updated: May 12, 2015.

INTRODUCTION The treatment of asthma is based upon assessment of severity and, in those already on therapy,
upon assessment of asthma control. Assessing initial asthma severity in children younger than 12 years of age,
determining when to start daily controller therapy, and assessing and monitoring control to determine if therapy
modifications are needed are discussed here.

Our approach to the management of asthma in children is based upon the National Asthma Education and
Prevention Program (NAEPP) Expert panel guidelines, published in 2007, that provide recommendations for the
management of chronic childhood asthma in children aged 0 to 4 years and 5 to 11 years [1]. Their recommendations
for the management of asthma in adolescents and adults are presented separately, as are detailed discussions about
use of controller and quick-relief medications in children younger than 12 years. (See "Treatment of intermittent and
mild persistent asthma in adolescents and adults" and "Treatment of moderate persistent asthma in adolescents and
adults" and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications"
and "Asthma in children younger than 12 years: Rescue treatment for acute symptoms".)

The initial evaluation and diagnosis of asthma in children younger than 12 years of age and the management of
acute asthma exacerbations in children are discussed separately. A general overview of asthma management and
asthma trigger identification and avoidance for patients of all ages are also presented separately. (See "Asthma in
children younger than 12 years: Initial evaluation and diagnosis" and "Acute asthma exacerbations in children:
Emergency department management" and "Acute asthma exacerbations in children: Inpatient management" and "An
overview of asthma management" and "Trigger control to enhance asthma management".)

ASSESSMENT OF SEVERITY IN PATIENTS NOT ON DAILY THERAPY Asthma severity is the intrinsic intensity
of disease. Initial assessment of patients who have confirmed asthma begins with a severity classification because
selection of the type, amount, and scheduling of therapy corresponds to the level of asthma severity. This
assessment is made immediately after diagnosis, or when the patient is first encountered, generally before the
patient is taking some form of long-term controller medication. Asthma severity does not predict the severity of
exacerbations. Even children with mild asthma can have severe exacerbations. (See "Asthma in children younger
than 12 years: Initial evaluation and diagnosis".)

Assessment of asthma severity is made on the basis of components of current impairment and future risk (table
1A-B) [2].

The factors used to determine impairment are:

The frequency of symptoms, nighttime awakenings, and use of short-acting beta agonists for symptom control
(not for prevention of exercise-induced symptoms) in the past two to four weeks, based upon patient/caregiver
recall.

The degree to which symptoms have interfered with normal activity in the past two to four weeks, based upon
patient/caregiver recall.

Spirometry results in children that are able to perform the test.

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Risk assessment is primarily based upon the patient/caregiver recall of the number of exacerbations in the past year
that have required treatment with oral glucocorticoids, although the severity of each exacerbation and the interval
since last exacerbation are also taken into consideration.

The severity is determined by the most severe category measured. As an example, a child who has symptoms
approximately four days per week, uses short-acting beta agonists approximately three days per week, has minor
limitations in normal activities, and has had only one course of oral glucocorticoids for an exacerbation in the past
year (all categorized as "mild"), but has had nighttime awakenings four times a month (categorized as "moderate") is
considered to have asthma of moderate severity.

If the assessment is made during a visit in which the patient is treated for an acute exacerbation, then asking the
patient to recall symptoms and short-acting beta agonist use in the period before the onset of the current
exacerbation will suffice to determine impairment until the following visit. (See "An overview of asthma management",
section on 'Goals of asthma treatment'.)

Assessment of asthma control and asthma severity in children already on controller medication, defined as the
degree of difficulty in achieving asthma control while on daily treatment, are discussed below. (See 'Assessment of
severity in patients on daily therapy' below and 'Assessment of control' below.)

INITIATION OF THERAPY The degree of severity while not on long-term controller medications determines which
"step" or level of initial therapy is needed (table 1A-B and figure 1A-B). Other factors, including the risk of developing
persistent asthma, are also taken into consideration in children under five years of age. Patients with intermittent
asthma require only occasional use of quick-relief medications, whereas patients with persistent asthma of any
severity should be started on daily controller therapy. Our recommendations are in accordance with the National
Asthma Education and Prevention Program (NAEPP) guidelines. How to decide which specific medication(s) to use
is discussed in greater detail separately. (See 'Assessment of severity in patients not on daily therapy' above and
"Asthma in children younger than 12 years: Rescue treatment for acute symptoms" and "Asthma in children younger
than 12 years: Treatment of persistent asthma with controller medications".)

Children 0 to 4 years old Initiation of controller medication for children ages zero to four years is based upon the
severity of symptoms and exacerbations, the frequency of exacerbations, and the risk of development of subsequent
asthma (table 1A).

We recommend initiating controller therapy in children who have had 4 episodes of wheezing in the past year that
lasted more than one day and affected sleep and who have the following risk factors for persistent asthma [3,4]:

One of the following Parental history of asthma, clinician diagnosis of atopic dermatitis, evidence of
sensitization to aeroallergens.

OR

Two of the following Evidence of sensitization to foods, 4 percent peripheral blood eosinophilia, wheezing
apart from colds.

We also suggest the initiation of controller medications for the following children [1]:

Those aged zero to four years who consistently require quick-relief medications more than two days per week
for a period of more than four weeks.

Infants and young children experiencing severe exacerbations less than six weeks apart or those who have two
or more exacerbations requiring systemic glucocorticoids within six months.

Children with intermittent disease who experience severe exacerbations, especially during periods when they
are likely to be exposed to known triggers, such as seasonal pollens or respiratory viruses [5].

Children 5 to 11 years old We agree with the NAEPP recommendations for the initiation of controller medications
for all children ages 5 to 11 years who have persistent asthma defined by symptom frequency, short-acting beta

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agonist use, impairment of normal activity, and risk for development of future exacerbations (table 1B) [1].

ASSESSMENT OF SEVERITY IN PATIENTS ON DAILY THERAPY It is more useful to assess degree of asthma
control rather than severity in patients who are already on daily controller asthma treatment. Thus, the Joint Task
Force of the American Thoracic Society and the European Respiratory Society also recommend defining asthma
severity as the degree of difficulty in achieving asthma control while on daily controller treatment in addition to the
components of severity discussed above [2]. (See 'Assessment of severity in patients not on daily therapy' above and
'Assessment of control' below.)

Severity may be influenced by the underlying phenotype, environmental and family function factors (including
smoking, stress, and violence), adherence to treatment, drug delivery technique, and comorbidities. As an example,
exposure to violence is associated with more symptom days and higher hospitalization rates [6,7].

Patients with severe asthma can include those who are untreated, who are difficult to treat, and who are maximally
treated but resistant to therapy [8,9]. As an example, children are considered to have severe asthma if they are
poorly controlled on several daily medications or if they are well controlled, but require three controller medications to
maintain asthma control.

ASSESSMENT OF CONTROL The National Asthma Education and Prevention Program (NAEPP) recommends
defining asthma control as the extent to which therapy reduces or eliminates the manifestations of asthma [2]. This
includes evaluation of the components of impairment and risk that are reviewed above, as well as assessment for
treatment-related adverse effects (table 2A-B). Medication side effects may impact adherence. In addition, significant
side effects may necessitate a change in medications even if the patients asthma is well controlled. The presence of
persistent asthma symptoms (impairment domain) is a risk factor for severe asthma exacerbations (risk domain),
although the predictors for each are different [10]. (See 'Assessment of severity in patients not on daily therapy'
above.)

In patients with established asthma, the history obtained at follow-up visits is helpful in determining the adequacy of
control and the risk of future exacerbations. Salient historical points include:

Medications and other therapies


Medical utilization
School attendance and performance
Physical activity
Psychosocial factors

The use of a standardized questionnaire, such as the Asthma Control Test (ACT) or Asthma Control Questionnaire,
facilitates the gathering of this information [11]. The Childhood Asthma Control Test (figure 2) is validated for use in
children aged 4 to 11 years [12]. The Test for Respiratory and Asthma Control in Kids (TRACK) questionnaire is
validated for preschool-aged children. This tool assesses impairment of asthma control (symptom burden, activity
limitations, and rescue use of bronchodilators) and is the first to also assess risk (oral glucocorticoid use in the past
12 months) [13-15]. The Asthma APGAR (Activities, Persistent triGgers, Asthma medications, Response to therapy)
system includes a patient/parent-completed questionnaire and an algorithm that uses the questionnaire answers to
guide asthma care [16]. The questionnaire collects information on "actionable items," such as asthma triggers,
treatment adherence, inhaler technique, and patient/parent perception of response to treatment, in addition to
assessment of control. The Asthma APGAR system was found to similarly assess asthma control compared with the
ACT. It appears to be a promising tool that provides additional guidance to aid clinicians in improving asthma care,
although further study of this system is needed before it is used routinely in clinical care.

Pulmonary function testing is recommended to assess asthma control (in children able to perform the technique
adequately), in addition to a careful assessment of symptoms and medication use. The available evidence does not
support a role for routine use of fractional exhaled nitric oxide (FeNO) measurement in the diagnosis or monitoring of
asthma in either children or adults, since the addition of FeNO to the usual monitoring for asthma control (table 2A-B)
is unlikely to change management [17]. (See "Asthma in children younger than 12 years: Initial evaluation and

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diagnosis", section on 'Spirometry' and "Asthma in children younger than 12 years: Initial evaluation and diagnosis",
section on 'Ancillary studies'.)

Suboptimal asthma control is associated with underuse of controller medications [18]. Other potentially modifiable
factors associated with poor control include parents' low expectations that controller medications will improve asthma
symptoms and high levels of worry about competing household priorities, such as jobs, money, safety, relationships,
and health of other family members.

MONITORING AND DOSING ADJUSTMENT Patients should be reevaluated after initiation of controller therapy
to determine its effectiveness. A reasonable interval is two to four weeks for patients diagnosed with moderate to
severe persistent asthma and four to six weeks for children with mild persistent asthma since two- to six-week
intervals are usually necessary to adequately assess the response to a given intervention (table 1A and table 1B).
The frequency of subsequent visits is determined by the level of asthma control (table 2A and table 2B). Patients with
well-controlled asthma can follow-up every one to six months to determine whether to continue the same regimen, or
step up or step down therapy (figure 1A and figure 1B). In contrast, those with not well-controlled asthma or very
poorly controlled asthma should follow-up in two to six weeks and two weeks, respectively, to evaluate their response
to step-up therapy. (See 'Assessment of control' above.)

Treatment with controller medications may be escalated at any time (table 2A-B and figure 1A-B). Options for step-up
therapy include increasing the dose of inhaled glucocorticoid, adding a long-acting beta agonist (LABA), or adding a
leukotriene-receptor antagonist (LTRA) [19]. Potential issues with each medication (eg, behavioral changes with
montelukast, skeletal effects and adrenal suppression with high-dose inhaled glucocorticoids, and the boxed warning
on the package insert regarding long-term use of LABAs) should be considered and discussed with patients and their
families when choosing step-up therapy. These concerns are discussed in greater detail separately in the specific
drug topics and other topics. Determining which controller therapies to use is also discussed in greater detail
separately. (See "Agents affecting the 5-lipoxygenase pathway in the treatment of asthma", section on 'Adverse
effects' and "Major side effects of inhaled glucocorticoids" and "Beta agonists in asthma: Controversy regarding
chronic use" and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller
medications".)

Adherence with the current regimen should be assessed before escalating therapy. Potentially modifiable factors
associated with underuse of controller medications include absence of a consistent routine for administration of
medications, poor technique administering medications, poor parental understanding and assessment of asthma
control, and parental concerns about the medications [18].

When asthma control has been achieved for at least three months, attempts should be made to reduce the regimen
at one- to two-month intervals as tolerated (table 2A-B and figure 1A-B). Acute exacerbations of asthma demand
more intensive management at any time, including the addition of oral glucocorticoids [20,21]. (See "Asthma in
children younger than 12 years: Rescue treatment for acute symptoms" and "Acute asthma exacerbations in children:
Emergency department management" and "Acute asthma exacerbations in children: Inpatient management".)

SUMMARY AND RECOMMENDATIONS

Asthma severity is the intrinsic intensity of disease. Initial assessment of patients who have confirmed asthma
begins with a severity classification because selection of the type, amount, and scheduling of therapy
corresponds to the level of asthma severity. This assessment is made immediately after diagnosis, or when the
patient is first encountered, generally before the patient is taking some form of long-term controller medication.
Assessment is made on the basis of components of current impairment and future risk (table 1A-B). (See
'Assessment of severity in patients not on daily therapy' above.)

The degree of severity while not on long-term controller medications determines which "step" or level of initial
therapy is needed (table 1A-B and figure 1A-B). Other factors, including the risk of developing persistent
asthma, are also taken into consideration in children under five years of age. Patients with intermittent asthma
require only occasional use of quick-relief medications, whereas patients with persistent asthma of any severity
should be started on daily controller therapy. (See 'Initiation of therapy' above and "Asthma in children younger

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than 12 years: Rescue treatment for acute symptoms" and "Asthma in children younger than 12 years:
Treatment of persistent asthma with controller medications".)

We recommend the use of daily controller medications in infants and children younger than 12 years with
persistent asthma of any severity (Grade 1A). (See 'Initiation of therapy' above.)

We also recommend the initiation of controller therapy for children aged zero to four years who had 4 episodes
of wheezing in the past year that lasted more than one day and affected sleep, and who have risk factors for
persistent asthma (Grade 1A). (See 'Children 0 to 4 years old' above.)

Additionally, we suggest the use of daily controller therapies for the following children (Grade 2C) (see 'Initiation
of therapy' above):

Children with intermittent asthma who experience severe exacerbations, especially during periods when
they are likely to be exposed to known triggers.

Those aged zero to four years who require reliever medications more than two days per week for a period
of more than four weeks.

Infants and young children experiencing severe exacerbations less than six weeks apart or those who
have two or more exacerbations requiring treatment with systemic glucocorticoids within six months.

In patients on daily controller therapy, asthma severity is defined as the degree of difficulty in achieving asthma
control while on daily treatment in addition to the components of impairment and risk. (See 'Assessment of
severity in patients on daily therapy' above.)

Asthma control is defined as the extent to which therapy reduces or eliminates the manifestations of asthma.
This includes evaluation of the components of impairment and risk that are reviewed above, as well as
assessment for treatment-related adverse effects (table 2A-B).

Patients should be reevaluated after initiation of controller therapy to determine its effectiveness. Treatment with
controller medications may be escalated (step up) at any time (table 2A-B and figure 1A-B), although adherence
with the current regimen should be assessed before escalating therapy. Attempts should be made to reduce the
regimen (step down) once asthma control has been achieved for at least three months. The frequency of
follow-up is determined by the severity of asthma and level of control. (See 'Monitoring and dosing adjustment'
above and "Asthma in children younger than 12 years: Treatment of persistent asthma with controller
medications", section on 'Step-up therapy' and "Asthma in children younger than 12 years: Treatment of
persistent asthma with controller medications", section on 'Step-down therapy'.)

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REFERENCES

1. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and
management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no.
08-4051) www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on December 04, 2014).
2. Reddel HK, Taylor DR, Bateman ED, et al. An official American Thoracic Society/European Respiratory Society
statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical
practice. Am J Respir Crit Care Med 2009; 180:59.
3. Guilbert TW, Morgan WJ, Zeiger RS, et al. Long-term inhaled corticosteroids in preschool children at high risk
for asthma. N Engl J Med 2006; 354:1985.
4. Castro-Rodrguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young
children with recurrent wheezing. Am J Respir Crit Care Med 2000; 162:1403.
5. Johnston NW, Mandhane PJ, Dai J, et al. Attenuation of the September epidemic of asthma exacerbations in

5 of 6 05/09/2016 5:58 AM
Asthma in children younger than 12 years: Initiating therapy and monitor... http://ezproxy.cavehill.uwi.edu:2110/contents/asthma-in-children-younge...

children: a randomized, controlled trial of montelukast added to usual therapy. Pediatrics 2007; 120:e702.
6. Sternthal MJ, Jun HJ, Earls F, Wright RJ. Community violence and urban childhood asthma: a multilevel
analysis. Eur Respir J 2010; 36:1400.
7. Wright RJ, Mitchell H, Visness CM, et al. Community violence and asthma morbidity: the Inner-City Asthma
Study. Am J Public Health 2004; 94:625.
8. Bousquet J, Mantzouranis E, Cruz AA, et al. Uniform definition of asthma severity, control, and exacerbations:
document presented for the World Health Organization Consultation on Severe Asthma. J Allergy Clin Immunol
2010; 126:926.
9. Ldrup Carlsen KC, Hedlin G, Bush A, et al. Assessment of problematic severe asthma in children. Eur Respir
J 2011; 37:432.
10. Wu AC, Tantisira K, Li L, et al. Predictors of symptoms are different from predictors of severe exacerbations
from asthma in children. Chest 2011; 140:100.
11. National Asthma Education and Prevention Program: Expert panel report 3 (EPR3): Guidelines for the
diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH
publication no. 08-4051). www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on February 11, 2010).
12. Liu AH, Zeiger R, Sorkness C, et al. Development and cross-sectional validation of the Childhood Asthma
Control Test. J Allergy Clin Immunol 2007; 119:817.
13. Murphy KR, Zeiger RS, Kosinski M, et al. Test for respiratory and asthma control in kids (TRACK): a caregiver-
completed questionnaire for preschool-aged children. J Allergy Clin Immunol 2009; 123:833.
14. Chipps B, Zeiger RS, Murphy K, et al. Longitudinal validation of the Test for Respiratory and Asthma Control in
Kids in pediatric practices. Pediatrics 2011; 127:e737.
15. Zeiger RS, Mellon M, Chipps B, et al. Test for Respiratory and Asthma Control in Kids (TRACK): clinically
meaningful changes in score. J Allergy Clin Immunol 2011; 128:983.
16. Rank MA, Bertram S, Wollan P, et al. Comparing the Asthma APGAR system and the Asthma Control Test in
a multicenter primary care sample. Mayo Clin Proc 2014; 89:917.
17. British Guideline on the Management of Asthma. Scottish Intercollegiate Guidelines Network (SIGN); British
Thoracic Society, 2008. http://www.sign.ac.uk/ (Accessed on May 08, 2015).
18. Smith LA, Bokhour B, Hohman KH, et al. Modifiable risk factors for suboptimal control and controller medication
underuse among children with asthma. Pediatrics 2008; 122:760.
19. Castro-Rodriguez JA, Rodrigo GJ. A systematic review of long-acting 2-agonists versus higher doses of
inhaled corticosteroids in asthma. Pediatrics 2012; 130:e650.
20. Canny GJ, Levison H. Childhood asthma: a rational approach to treatment. Ann Allergy 1990; 64:406.
21. Kamada AK, Szefler SJ. Pharmacological management of severe asthma, Marcel Dekker, New York 1996.

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