Patient education: Asthma treatment in children (Beyond the Basics)
- Gregory Sawicki, MD, MPH
Gregory Sawicki, MD, MPH
- Assistant Professor of Pediatrics
- Harvard Medical School
- Kenan Haver, MD
Kenan Haver, MD
- Assistant Professor of Pediatrics
- Harvard Medical School
ASTHMA TREATMENT OVERVIEW
The optimal treatment of asthma depends upon a number of factors, including the child's age, the severity and frequency of asthma attacks, and the ability to properly use the prescribed medications. For the great majority of children, asthma treatment can control symptoms, allowing the child to participate fully in all activities, including sports.
Successful treatment of asthma involves three components:
●Controlling and avoiding asthma triggers
●Regularly monitoring asthma symptoms and lung function
●Understanding how and when to use medications to treat asthma
This article discusses the treatment of asthma in children younger than 12 years. Children with asthma who are 12 years and older are treated with medications and doses similar to that of adults.
Separate articles discuss the symptoms and diagnosis of asthma and use of asthma dose inhalers in children. (See "Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)" and "Patient education: Asthma inhaler techniques in children (Beyond the Basics)" and "Patient education: Trigger avoidance in asthma (Beyond the Basics)".)
A number of topics about asthma in adults are also available. (See "Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient education: How to use a peak flow meter (Beyond the Basics)" and "Patient education: Asthma inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma and pregnancy (Beyond the Basics)".)
CONTROLLING ASTHMA TRIGGERS
The factors that set off or worsen asthma symptoms are called triggers. Identifying and avoiding asthma triggers, when possible, are essential in preventing asthma flare-ups. Trigger avoidance is discussed in detail in a separate article. (See "Patient education: Trigger avoidance in asthma (Beyond the Basics)".)
Common asthma triggers generally fall into several categories:
●Allergens (including dust, pollens, and furred animals)
●Irritants (such as tobacco smoke, aerosol sprays, some cleaning products)
After identifying potential asthma triggers, the parent and healthcare provider should develop a plan to deal with the triggers. If possible, the child should completely avoid or limit exposure to the trigger (eg, eliminate exposure to cigarette smoke). Recommendations may be made about decreasing allergen exposure for those children with allergies (eg, removing carpets from bedrooms, not allow pets to sleep in the child's room). Children who have persistent problems despite efforts to avoid triggers may benefit from seeing an asthma specialist. Some children may need adjustment in their medications, refinement in their technique, or instruction for proper administration. Others may have a different disease that has features in common with asthma, or they may have another problem in addition to asthma.
Exercise is an exception to the general rule about trigger avoidance. Exercise is encouraged for all children, including those with asthma. An asthma action plan should include steps to prevent and treat exercise-related symptoms. (See 'Exercise-induced asthma' below.)
MONITORING ASTHMA SYMPTOMS AND LUNG FUNCTION
Successful management of asthma requires the parent and/or child to monitor their asthma regularly. This is primarily done by recording the frequency and severity of asthma symptoms (coughing, shortness of breath, and wheezing).
In addition, a healthcare provider may recommend that the child measure his or her lung function with a test known as a peak flow (peak expiratory flow rate [PEFR]).
Asthma questionnaires — A healthcare provider may recommend keeping a daily asthma diary when symptoms are not well controlled or when starting a new treatment. In the diary, asthma symptoms (eg, coughing, wheezing) and medications are recorded. The child’s peak flow readings may also be included (form 1). A standardized questionnaire, such as the Asthma Control Test (ACT)  or Asthma Control Questionnaire (ACQ) , may be recommended to help track asthma symptoms. The asthma control test is available online .
A periodic diary may be recommended for children who have stable symptoms and whose medications have not changed recently. This type of diary can be completed before visiting the healthcare provider and helps the parent/child and healthcare provider to determine if the asthma treatment plan needs to be adjusted (form 2).
Lung function assessment — Children over the age of six years may have lung function testing (spirometry) performed during a visit with their healthcare provider. In addition, a healthcare provider may recommend measurements of PEFR. PEFR measures the rate at which a person can exhale and depends upon the degree of airway narrowing and patient effort. PEFR monitoring can provide data that can be used to make treatment decisions. This is discussed in greater detail elsewhere. (See "Patient education: How to use a peak flow meter (Beyond the Basics)" and "Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)", section on 'Spirometry testing'.)
Review of asthma treatment — Routine follow-up appointments with a healthcare provider are recommended to review asthma symptom control and treatment plans. Children with asthma should see a healthcare provider every one to six months to monitor the child's symptom severity and frequency and response to treatment. The medications used to treat asthma in children vary according to a child's age, the severity of asthma, and the level of asthma symptom control. If control has been adequate for at least three months, the asthma medication dose may be decreased. If control is not adequate, the medication schedule, delivery technique, and trigger avoidance will be reviewed, and the medication dose may be increased or additional medication prescribed.
CATEGORIES OF ASTHMA SYMPTOMS
Intermittent asthma — A child is defined as having intermittent asthma if he or she has asthma with minimal symptoms and infrequent asthma flares. Specifically, children with intermittent asthma have the following characteristics:
●Symptoms of asthma occur two or fewer times per week
●Asthma does not interfere with daily activities
●Awakenings during the night due to asthma symptoms occur two or fewer times per month
●Asthma flares require oral glucocorticoids (also called corticosteroids or steroids) no more than once per year
A child with asthma symptoms that are triggered only during exercise (exercise-induced bronchoconstriction) may have intermittent asthma. However, symptoms during exercise may also indicate that the child may have persistent asthma. (See "Patient education: Exercise-induced asthma (Beyond the Basics)".)
Persistent asthma — Children with persistent asthma have symptoms regularly. There may be days when activities are limited due to asthma symptoms, and the child may be awakened from sleep. Lung function is usually normal between episodes, but becomes abnormal during an asthma attack. Persistent asthma can be mild, moderate, or severe.
The criteria that are used to determine a child's asthma severity include the number of days per week that a child has one or more of the following:
●Symptoms, such as cough, wheeze, or shortness of breath
●Awakenings during the night due to cough or wheeze
●Use of a bronchodilator (reliever medication)
●Symptoms that affect the child's ability to participate in normal activities
The number of asthma flares (also called exacerbations or episodes) per year that require treatment with oral glucocorticoids (also called corticosteroids or steroids) are also taken into consideration when determining asthma severity.
Consultation with an asthma specialist (a pulmonologist or allergist) is recommended for children who have moderate or severe persistent asthma, as well as those ages zero to four years who have any form of persistent asthma.
QUICK-RELIEF MEDICATIONS FOR ASTHMA
Bronchodilators — Short-acting bronchodilators (also called beta-2 agonists) relieve asthma symptoms rapidly by relaxing the muscles around narrowed airways. In the United States, albuterol (Ventolin, Proventil, ProAir, ProAir RespiClick, and others) is the most commonly used short-acting bronchodilator. These medications are sometimes referred to as "quick-acting relievers." Children with intermittent asthma, the mildest form of asthma, will require these symptom-relieving medications only occasionally.
There is no benefit to using short-acting bronchodilators on a regular basis, and there may be some harm. If asthma symptoms are occurring more than twice per week on a regular basis, the child should be evaluated by a healthcare provider. Other medications are recommended for persistent symptoms in this situation.
Metered-dose inhaler versus nebulizer — Short-acting bronchodilators can be delivered with a nebulizer or through a metered-dose inhaler with an attached spacer (valved holding device) device and an infant- or child-sized mask. (See "Delivery of inhaled medication in children".)
●Nebulizers use compressed air to change a medication from liquid form to a fine spray that can be inhaled through a mask or mouthpiece (picture 1). When a facemask is used, it should be placed snugly over the face; moving the mask just 1 centimeter away from the face reduces the dose of an inhaled medication by up to 50 percent. Nebulizers may be preferred to metered-dose inhalers for children who are unable to use a handheld device. (See "Use of medication nebulizers in children".)
●Metered-dose inhalers dispense liquid or fine powder medications, which mix with the air that is breathed into the lungs. The spacer and face mask help to ensure that the greatest amount of medication is delivered to the lungs (picture 1). It is preferable to have the child use the inhaler when he or she is awake and not crying. The priming recommendations (number of times the inhaler should be sprayed into the air before first use or after the inhaler has not been used in a while) should be confirmed for each device. (See "Patient education: Asthma inhaler techniques in children (Beyond the Basics)".)
Side effects of bronchodilators — Some children feel shaky, have an increased heart rate, or become hyperactive after using a short-acting bronchodilator. The side effects often decrease over time.
CONTROLLER MEDICATIONS FOR ASTHMA
Children with persistent asthma need to take medication on a daily basis to keep their asthma under control, even if there are no symptoms of active asthma on a given day. Medications taken daily for asthma are called "long-term controller" medicines and function to decrease inflammation (or swelling) of the small airways over time. (See "Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)
Some controller medicines are delivered by inhaler or nebulizer, while others are taken as a pill or granules. The doses and types of controller medications prescribed to children with asthma depend on a child's asthma severity and level of symptom control.
Inhaled glucocorticoids — Inhaled glucocorticoids work by reducing swelling and sensitivity of the bronchial tubes, thereby reducing their exaggerated reaction to asthma triggers. These medications are the preferred treatment for persistent asthma. Regular treatment with an inhaled glucocorticoid medication can reduce the frequency of symptoms (and the need for inhaled bronchodilators), improve quality of life, and decrease the risk of a serious asthma attack.
Inhaled glucocorticoids can lead to a modest (1.2 cm [0.47 inches]) reduction in height in children. This decrease in height persisted into adulthood. The decrease was neither progressive nor cumulative. (See "Patient education: Asthma inhaler techniques in children (Beyond the Basics)".)
Side effects of glucocorticoids — Unlike glucocorticoids that are taken by mouth, very little of the inhaled glucocorticoid is absorbed into the bloodstream, and there are few side effects. As the dose of inhaled glucocorticoids is increased, more of the medication is absorbed into the bloodstream, and the risk of side effects increases.
The most common side effect of inhaled glucocorticoids is oral candidiasis (thrush). This can usually be prevented by taking inhaled glucocorticoids with a spacer with or without a face mask (which helps to deliver medication to the lungs rather than the mouth). The child should rinse his or her mouth or brush teeth and tongue immediately after inhalation. A hoarse voice and sore throat (without thrush) are less common side effects that are usually managed by changing to a different glucocorticoid preparation.
Inhaled glucocorticoids can lead to a modest (1.2 cm [0.47 inches]) reduction in height in children. This decrease in height persisted into adulthood. The decrease was neither progressive nor cumulative .
Although the side effects of glucocorticoids are of concern to many parents, it is important to remember that untreated asthma itself can prevent the child from participating in activities, influence the way a child perceives his or her wellbeing, and place the child at risk for an asthma exacerbation.
The goal of treatment is to use the lowest possible dose while maintaining good asthma control and minimizing the risk of serious asthma attacks. This usually means that treatment will be adjusted frequently, depending upon how well symptoms are controlled.
Leukotriene modifiers — A category of medications called leukotriene modifiers are sometimes used as an alternative to low-dose inhaled glucocorticoids in children who have mild persistent asthma. However, leukotriene modifiers are generally not as effective as inhaled glucocorticoids. The leukotriene modifier montelukast (Singulair) is taken by mouth once daily and is available as a chewable pill or granules that can be taken directly or mixed into certain soft foods.
Leukotriene modifiers can be used in addition to inhaled glucocorticoids in children who have more severe and/or difficult-to-control asthma.
There are worries that montelukast might be linked to an increase in side effects like mood changes and aggressive behavior. Parents should notify the child’s healthcare provider if any changes in mood or behavior occur after starting this medication.
Long-acting bronchodilators — Long-acting bronchodilators (also called long-acting beta agonists, or LABA) are bronchodilators that have a longer-lasting effect (at least 12 hours) compared with the short-acting beta agonists that are used as reliever medications. (See 'Quick-relief medications for asthma' above.)
These medications (LABA) should be used only in combination with an inhaled glucocorticoid; they should not be used alone. Combination therapy is used as step-up therapy for children not well controlled on inhaled glucocorticoids or montelukast alone.
Omalizumab — Omalizumab is a medication that targets a specific type of protein in the blood (called immunoglobin E, or "IgE"). It may be an option for certain children over six years of age whose asthma is not well controlled with inhaled glucocorticoids. (See 'Inhaled glucocorticoids' above.)
An article that discusses exercise-induced asthma is available separately. If exercise is a trigger for asthma, the child can take an extra dose of bronchodilator medication or leukotriene modifier before exercise. (See "Patient education: Exercise-induced asthma (Beyond the Basics)".)
ASTHMA ATTACK TREATMENT
The term "asthma attack" is somewhat confusing because it does not distinguish between a mild increase in symptoms and a life-threatening episode. Asthma symptoms may be aggravated by changes in air quality, the common cold and other respiratory infections, and new or continued exposure to triggers. These triggers can cause mild, moderate, or severe asthma symptoms to develop. Any of these changes could be considered an asthma "attack." Even children with what is classified as mild disease can experience severe exacerbations.
Some children will have periodic, mild asthma attacks that never require emergency care, while others may have severe and sudden asthma attacks that require a call for emergency medical attention. Even children with mild asthma can have severe exacerbations.
Asthma action plan — The child and/or parent will work with their healthcare provider to develop tailored guidelines (also called an action plan) to follow when symptoms increase. Asthma action plans are available for children up to age five years (form 3), for children five years and older and adults (form 4), and for school (Student Asthma Action Card).
Asthma symptoms are divided into three zones, which are assigned colors similar to those of a traffic light. These zones can be used to make decisions about the need for treatment:
Green — Green signals that the lungs are functioning well. When asthma symptoms are not present or are well controlled, patients should continue their regular medicines and activities.
Yellow — Yellow is a sign that the airways in the lungs are somewhat narrowed, making it difficult to move air in and out; this occurs when there is an increase in asthma symptom frequency or severity. A short-term change or increase in medication is generally required. Patients should change or increase their asthma medication according to the plan that was discussed with their provider.
Red — Red is a sign that the airways are severely narrowed and requires immediate treatment; this occurs with a significant increase in asthma symptoms. The quick-acting reliever inhaler should be used according to the plan discussed with the provider, and the child should be evaluated by a medical professional.
Emergency care plan — Parents should work with their child's healthcare provider to formulate an emergency care plan that explains specifically what to do if asthma symptoms worsen. This may include more frequent use of a reliever medication.
However, if asthma symptoms worsen or do not improve after use of a quick-acting reliever medication, the parent should immediately call for emergency medical assistance. Severe asthma attacks can be fatal if not treated promptly.
In most areas of the United States, emergency medical assistance is available by calling 911. Parents should not attempt to drive to the hospital and should not ask someone else to drive. Calling 911 is safer than driving for two reasons:
●From the moment emergency medical services (EMS) personnel arrive, they can begin evaluating and treating asthma. If a parent drives to the hospital, treatment cannot begin until the child arrives at the emergency department.
●If a dangerous complication of asthma occurs on the way to the hospital, EMS personnel may be able to treat the problem immediately.
Following an asthma attack, most children are given a 3- to 10-day course of an oral glucocorticoid medication (eg, prednisone, prednisolone). This treatment helps to decrease the swelling and mucus production in the lungs and reduces the risk of a second asthma attack.
Wear medical identification — Many children with medical conditions wear a bracelet, necklace, or similar alert tag at all times. If an accident occurs and the child cannot explain his or her condition, this will help responders provide appropriate care.
The alert tag should include a list of major medical conditions and allergies, as well as the name and phone number of an emergency contact. One device, Medic Alert (www.medicalert.org/), provides a toll-free number that emergency medical workers can call to find out a person's medical history, list of medications, family emergency contact numbers, and healthcare provider names and numbers.
WHERE TO GET MORE INFORMATION
Your child’s healthcare provider is the best source of information for questions and concerns related to your child’s medical problem.
This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.
Patient level information — UpToDate offers two types of patient education materials.
The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Patient education: Asthma in children (The Basics)
Patient education: Avoiding asthma triggers (The Basics)
Patient education: How to use your child’s metered dose inhaler (The Basics)
Patient education: How to use your child’s dry powder inhaler (The Basics)
Patient education: Medicines for asthma (The Basics)
Patient education: Breathing tests (The Basics)
Patient education: Enterovirus D68 (The Basics)
Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.
Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)
Patient education: Asthma inhaler techniques in children (Beyond the Basics)
Patient education: Trigger avoidance in asthma (Beyond the Basics)
Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)
Patient education: How to use a peak flow meter (Beyond the Basics)
Patient education: Asthma inhaler techniques in adults (Beyond the Basics)
Patient education: Asthma and pregnancy (Beyond the Basics)
Patient education: Exercise-induced asthma (Beyond the Basics)
Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.
Acute asthma exacerbations in children: Emergency department management
Acute severe asthma exacerbations in children: Intensive care unit management
An overview of asthma management
Approach to wheezing in infants and children
Aspirin-exacerbated respiratory disease
Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications
Asthma in children younger than 12 years: Epidemiology and pathophysiology
Asthma in children younger than 12 years: Initial evaluation and diagnosis
Asthma in children younger than 12 years: Rescue treatment for acute symptoms
Natural history of asthma
Peak expiratory flow rate monitoring in asthma
Risk factors for asthma
Subcutaneous immunotherapy for allergic disease: Indications and efficacy
The impact of breastfeeding on the development of allergic disease
Delivery of inhaled medication in children
Use of medication nebulizers in children
The following organizations also provide reliable health information.
●The National Library of Medicine
●American College of Allergy, Asthma, and Immunology
- Childhood Asthma Control Test. http://www.asthma.com/resources/childhood-asthma-control-test.html (Accessed on May 15, 2013).
- Asthma Control Questionnaire. http://www.qoltech.co.uk/acq.html.
- http://www.asthma.com (Accessed on October 09, 2015).
- Kelly HW, Sternberg AL, Lescher R, et al. Effect of inhaled glucocorticoids in childhood on adult height. N Engl J Med 2012; 367:904.
- 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 September 01, 2007).
- Bisgaard H, Szefler S. Long-acting beta2 agonists and paediatric asthma. Lancet 2006; 367:286.
- 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.
- Sorkness CA, Lemanske RF Jr, Mauger DT, et al. Long-term comparison of 3 controller regimens for mild-moderate persistent childhood asthma: the Pediatric Asthma Controller Trial. J Allergy Clin Immunol 2007; 119:64.
All topics are updated as new information becomes available. Our peer review process typically takes one to six weeks depending on the issue.