Asthma is one of the most common chronic diseases in children, characterized by reversible airway obstruction, bronchial hyperresponsiveness, and inflammation. Effective asthma management aims to achieve symptom control, prevent exacerbations, and maintain normal activity levels. Below is a comprehensive guide to prescribing for childhood asthma.
1. Goals of Asthma Management
- Relieve and prevent symptoms (e.g., wheezing, coughing, breathlessness).
- Minimize exacerbations.
- Achieve optimal lung function.
- Avoid adverse effects of medications.
2. Key Components of Asthma Management
- Assessment:
- Classify severity: intermittent, mild, moderate, or severe persistent.
- Identify triggers (e.g., allergens, infections, exercise).
- Assess inhaler technique and adherence.
- Control Plan:
- Stepwise approach based on symptom control.
- Include both reliever and controller medications.
- Education:
- Teach proper inhaler use.
- Develop an individualized asthma action plan.
3. Pharmacological Therapy
a. Relievers (Acute Symptom Relief)
1. Short-Acting Beta-2 Agonists (SABAs)
- Examples: Salbutamol (Albuterol), Terbutaline.
- Mechanism:
- Relax airway smooth muscle, providing rapid relief from bronchospasm.
- Dosage:
- Salbutamol: 2 puffs (100 mcg each) every 4–6 hours as needed.
- Nebulized: 2.5 mg every 4–6 hours.
- Indications:
- Acute symptoms or exacerbations.
- Side Effects:
- Tachycardia, tremors, nervousness.
b. Controllers (Long-Term Management)
1. Inhaled Corticosteroids (ICS)
- Examples: Budesonide, Fluticasone, Beclomethasone.
- Mechanism:
- Reduce airway inflammation, preventing symptoms and exacerbations.
- Dosage:
- Budesonide: 200–400 mcg/day, divided into 2 doses.
- Fluticasone: 100–200 mcg/day.
- Indications:
- First-line controller therapy for persistent asthma.
- Side Effects:
- Oral thrush (minimized with spacer use and mouth rinsing), hoarseness.
2. Long-Acting Beta-2 Agonists (LABAs)
- Examples: Salmeterol, Formoterol.
- Mechanism:
- Provide sustained bronchodilation.
- Dosage:
- Salmeterol: 50 mcg twice daily.
- Always combined with ICS (e.g., Fluticasone + Salmeterol).
- Indications:
- Add-on therapy for moderate-to-severe asthma.
3. Leukotriene Receptor Antagonists (LTRAs)
- Example: Montelukast.
- Mechanism:
- Block leukotriene-mediated inflammation and bronchoconstriction.
- Dosage:
- Montelukast: 4 mg (ages 2–5), 5 mg (ages 6–14) once daily.
- Indications:
- Alternative or add-on therapy, especially in allergen-driven asthma.
- Side Effects:
- Rare neuropsychiatric effects (e.g., mood changes, nightmares).
4. Biologic Agents
- Examples: Omalizumab (anti-IgE), Mepolizumab (anti-IL-5).
- Indications:
- Severe allergic or eosinophilic asthma unresponsive to standard therapy.
- Administration:
- Subcutaneous injections every 2–4 weeks.
- Precautions:
- Require specialist initiation and monitoring.
4. Stepwise Approach to Asthma Management in Children
Step 1: Intermittent Asthma
- Reliever: SABA as needed.
- No daily controller required.
Step 2: Mild Persistent Asthma
- Controller: Low-dose ICS.
- Reliever: SABA as needed.
Step 3: Moderate Persistent Asthma
- Controller: Low-dose ICS + LABA or medium-dose ICS.
- Alternative: Low-dose ICS + Montelukast.
- Reliever: SABA as needed.
Step 4: Severe Persistent Asthma
- Controller: Medium/high-dose ICS + LABA.
- Add-on: LTRA or Biologics (specialist guidance).
- Reliever: SABA as needed.
Step 5: Refractory Asthma
- Referral to a specialist for:
- High-dose ICS + LABA.
- Biologic agents or oral corticosteroids.
5. Managing Acute Exacerbations
a. Mild
- Treatment:
- SABA (2–4 puffs via MDI with spacer, repeat every 20 minutes for 1 hour if needed).
- Monitor response and continue as needed.
b. Moderate
- Treatment:
- SABA via nebulizer or MDI (every 20 minutes for 3 doses).
- Oral corticosteroids (e.g., Prednisolone 1–2 mg/kg/day for 3–5 days).
- Monitoring:
- Pulse oximetry (>92% SpO₂ indicates adequate oxygenation).
c. Severe
- Treatment:
- Nebulized SABA + Ipratropium bromide (every 20 minutes for 1 hour).
- Systemic corticosteroids (e.g., Intravenous Hydrocortisone).
- Supplemental oxygen.
- Consider magnesium sulfate if unresponsive.
- Referral:
- Admit for intensive care if no improvement.
6. Monitoring and Follow-Up
- Symptom Monitoring:
- Assess control using tools like the Asthma Control Test (ACT).
- Inhaler Technique:
- Regularly review and correct inhaler and spacer use.
- Growth Monitoring:
- Monitor height and weight in children on ICS therapy.
- Lung Function Tests:
- Perform spirometry or peak flow monitoring in children ≥5 years.
7. Patient and Family Education
- Asthma Action Plan:
- Provide a written plan detailing symptom recognition and steps for acute management.
- Trigger Avoidance:
- Identify and minimize exposure to allergens, smoke, pollution, and infections.
- Medication Adherence:
- Stress the importance of regular use of controller medications.
- Emergency Preparedness:
- Educate parents on recognizing severe symptoms and when to seek medical attention.
8. Special Considerations
- Infants and Young Children:
- Use spacers with masks for inhaled therapies.
- Montelukast is often preferred due to ease of administration.
- Exercise-Induced Asthma:
- Pre-treat with SABA 15 minutes before exercise.
- Comorbidities:
- Address allergic rhinitis, gastroesophageal reflux, or obesity if present.
Summary Table
| Category | Medication Examples | Indication | Side Effects |
|---|---|---|---|
| Relievers | Salbutamol | Acute symptom relief | Tremors, tachycardia |
| Controllers | Budesonide, Montelukast | Long-term inflammation control | Oral thrush, neuropsychiatric effects |
| Severe Asthma | Omalizumab | Refractory asthma | Injection site reactions |
| Acute Exacerbation | Prednisolone | Severe exacerbations | Hyperglycemia, irritability |
Conclusion
Childhood asthma management requires a stepwise, individualized approach that combines pharmacological treatment with education and monitoring. By tailoring therapy based on severity and response, healthcare professionals can achieve effective symptom control, minimize exacerbations, and enhance quality of life for children with asthma.
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