Patient information: Asthma treatment in children

ASTHMA TREATMENT OVERVIEW

The optimal treatment of asthma depends upon a number of factors, including the child's age and the severity and frequency of asthma attacks. For most children, asthma treatment can control symptoms, allowing the child to participate fully in activities and sports.

Successful treatment of asthma involves three components:

• Controlling and avoiding asthma triggers
• Regularly monitoring asthma symptoms and lung function
• Understanding how 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 information: Asthma symptoms and diagnosis in children" and "Patient information: Asthma inhaler techniques in children" and "Patient information: Trigger avoidance in asthma".)

A number of topics about asthma in adults are also available. (See "Patient information: Asthma treatment in adolescents and adults" and "Patient information: How to use a peak flow meter" and "Patient information: Asthma inhaler techniques in adults" and "Patient information: Pregnancy and asthma".)

CONTROLLING ASTHMA TRIGGERS

The factors that set off or worsen asthma symptoms are called triggers. Identifying and avoiding asthma triggers is essential in preventing asthma flare-ups. Trigger avoidance is discussed in detail in a separate article. (See "Patient information: Trigger avoidance in asthma".)

Common asthma triggers generally fall into several categories:

• Allergens (including dust, pollens, and furred animals)
• Respiratory infections
• Irritants (such as tobacco smoke or aerosol sprays)
• Exercise

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, remove carpets from bedrooms, do 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 allergy specialist.

Exercise is an exception to the general rule about trigger avoidance. Exercise is encouraged for children 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 peak expiratory flow rates (PEFRs). Routine follow-up appointments with a healthcare provider are recommended to review asthma symptom control and treatment plans.

Asthma diary — A healthcare provider may recommend keeping a daily asthma diary when symptoms are not well controlled or when starting a new treatment. On the diary, the child's peak flow readings, asthma symptoms (eg, coughing, wheezing), and medications are recorded (algorithm 1).

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 (graph 1).

Peak expiratory flow rate — Peak expirator flow rate (PEFR) measures the rate at which a person can exhale. This rate depends upon the degree of airway narrowing. PEFR monitoring can provide data that can be used to make treatment decisions. Children five years of age and older are usually capable of performing peak flow measurements. For more information, (see "Patient information: How to use a peak flow meter".

Review of asthma treatment — Children with asthma usually see a healthcare provider every one to six months to monitor the child's symptom severity and frequency and response to treatment. 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.

CATEGORIES OF ASTHMA SYMPTOMS

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. A child's asthma treatment plan must be monitored and adjusted on a regular basis. If symptoms are well controlled, medication can often be reduced. As symptoms worsen, medication should be increased.

Intermittent asthma — A child is defined as having intermittent asthma if he or she has asthma minimal symptoms and infrequent asthma flares. Specifically, children with intermittent asthma have the following characteristics (table 1A-B):

• 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 steroids) no more than once per year

A child with asthma symptoms that are triggered only during vigorous exercise (exercise-induced bronchoconstriction) might fit into this category, even if the child exercises more than twice per week. (See "Patient information: Exercise-induced asthma".)

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 (table 1A-B):

• Symptoms such as cough, wheeze, and 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

Consultation with an asthma specialist (a pulmonologist or allergist) is recommended for children who have moderate or severe persistent asthma as well as those age 0 to 4 years who have any form of persistent asthma.

RELIEVER 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®, and many 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. 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 more effective 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 device and infant- or child-sized mask.

• 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 one 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 too ill or too young to use a hand-held device, and in situations where large drug doses are necessary.
• 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 2). It is preferable to have the child use the inhaler when he or she is awake and not crying. (See "Patient information: Asthma inhaler techniques in children".)

Side effects of bronchodilators — Some children feel shaky, have an increased heart rate, or become hyperactive after using a short-acting bronchodilator. Using a single puff of the inhaler may reduce these side effects and only minimally decrease the inhaler's benefit. 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 (table 2).

Some controller medicines are delivered by inhaler while others are taken as a pill or liquid. The doses and types of controller medications prescribed to children with asthma depend on a child's asthma severity and level of symptom control (graph 2A-B).

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 glucocorticoids 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 may be taken with a metered dose inhaler, spacer, and face mask, or by nebulizer. These medications need to be taken on a daily basis to effectively control asthma symptoms. An inhaled bronchodilator is still used as needed to relieve symptoms and before exposure to asthma triggers. (See "Patient information: Asthma inhaler techniques in children".)

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 low-dose inhaled glucocorticoids is oral candidiasis (thrush). This can usually be prevented by taking inhaled glucocorticoids with a spacer and face mask (which helps to deliver medication to the lungs rather than the mouth). The child should rinse their mouth or brush their 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.

The most common side effect from long-term use of moderate or high-dose inhaled glucocorticoids is temporary slowing of growth; the body adjusts to a normal growth rate within the first year of use. Other rare but possible side effects include cataracts, increased pressure in the eye (glaucoma), and increased bone loss (osteoporosis).

Although the side effects of glucocorticoids are of concern to many parents, it is important to remember that untreated asthma itself can slow growth, prevent the child from participating in activities, and influence the way a child perceives his or her well-being.

In addition, the risk of side effects is far less with inhaled glucocorticoids than with oral glucocorticoids (eg, prednisolone). 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 may be used in addition to inhaled glucocorticoids. The leukotriene modifier montelukast (Singulair®) is taken as a chewable pill or granule by mouth once daily, and has few side effects. However, compared to inhaled glucocorticoids, leukotriene modifiers are somewhat less effective. Leukotriene modifiers can be used to prevent asthma symptoms before exposure to a trigger or before exercising.

Cromolyn — Cromolyn (Intal®) may be recommended as an alternative to low-dose inhaled glucocorticoids for children with mild persistent asthma. This medicine is not a glucocorticoid, and works by decreasing the activity of allergy cells. It is taken via metered dose inhaler, but is generally less effective than inhaled glucocorticoids. It is also less convenient, as it must be taken three or four times per day. Cromolyn can be used to prevent asthma symptoms before exposure to a trigger or before exercising.

EXERCISE-INDUCED ASTHMA

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, leukotriene modifier, or cromolyn before exercise. The child should not use more than twice the amount of medication normally used. (See "Patient information: Exercise-induced asthma".)

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 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".

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.

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 or the peak flow rate begins to decrease. An asthma action plan for children up to age five is shown in figure 3 (figure 1), for children five and older and adults in figure 4 (figure 2), and a school asthma action plan is shown in figure 5 (figure 3A-C).

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 significantly 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.

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 EMS personnel arrive, they can begin evaluating and treating asthma. If a parent drives to the hospital, treatment cannot begin until the child arrives in 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 three to ten day course of an oral glucocorticoid medication (eg, prednisone, prednisolone). This treatment helps to reduce 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 their 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.com), 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 healthcare provider is the best source of information for questions and concerns related to your medical problem. Because no two people are exactly alike and recommendations can vary from one person to another, it is important to seek guidance from a provider who is familiar with your individual situation.

This discussion will be updated as needed every four months on our web site (www.uptodate.com/patients). Additional topics as well as selected discussions written for healthcare professionals are also available for those who would like more detailed information.

Some of the most pertinent include:

Patient Level Information:
Patient information: A guide to asthma
Patient information: Asthma symptoms and diagnosis in children
Patient information: Asthma inhaler techniques in children
Patient information: Trigger avoidance in asthma
Patient information: Asthma treatment in adolescents and adults
Patient information: How to use a peak flow meter
Patient information: Asthma inhaler techniques in adults
Patient information: Pregnancy and asthma
Patient information: Exercise-induced asthma

Professional Level Information:
Acute asthma exacerbations in children: Outpatient management
Acute severe asthma exacerbation in children: Intensive care unit management
An overview of asthma management
Anticholinergic agents in the management of acute exacerbations of asthma
Approach to wheezing in children
Aspirin exacerbated respiratory disease
Chronic asthma in children younger than 12 years: Controller medications
Chronic asthma in children younger than 12 years: Definition, epidemiology, and pathophysiology
Chronic asthma in children younger than 12 years: Evaluation and diagnosis
Chronic asthma in children younger than 12 years: Quick-relief agents
Exercise-induced bronchoconstriction
Natural history of asthma
Nocturnal 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
Patient information: A guide to asthma

A number of web sites have information about medical problems and treatments, although it can be difficult to know which sites are reputable. Information provided by the National Institutes of Health, national medical societies and some other well-established organizations are often reliable sources of information, although the frequency with which they are updated is variable.

• The National Library of Medicine

      (www.nlm.nih.gov/medlineplus/healthtopics.html)

• National Heart, Lung, and Blood Institute

      (www.nhlbi.nih.gov/)

• American Lung Association

      (www.lungusa.org)

• What's Asthma All About?

      (www.whatsasthma.org)

• The Asthma and Allergy Foundation of America

      (www.aafa.org)

• American Academy of Allergy, Asthma, and Immunology

      (www.aaaai.org/patients.stm)

• American College of Allergy, Asthma, and Immunology

      (www.acaai.org/public/)

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