Current guidelines for the management of asthma in young children

Abstract

The diagnosis and management of asthma in young children is difficult, since there are many different wheezy phenotypes with varying underlying aetiologies and outcomes. This review discusses the different approaches to managing young children with wheezy illnesses presented in recently published global guidelines. Four major guidelines published since 2007 are considered. Helpful approaches are presented to assist the clinician to decide whether a clinical diagnosis of asthma can, or should be made in a young child with a recurrent wheezy illness and which treatments would be appropriate, dependent on risk factors, age of presentation, response to initial treatment and safety considerations. Each of the guidelines provide useful information for clinicians assessing young children with recurrent wheezy illnesses. There are differences in classification of the disease and treatment protocols. Although a firm diagnosis of asthma may only be made retrospectively in some cases and there are several effective guidelines to initiating treatment. Consistent review of the need for ongoing treatment with a particular pharmacological modality is essential, since many children with recurrent wheezing in infancy go into spontaneous remission. It is probable that newer biomarkers of airway inflammation will assist the clinician as to when to initiate and when to continue pharmacological treatment in the future.

Keywords: Asthma; guideline; preschool child.

Fig. 1

Stepwise approach for managing asthma in children 0-4 yr of age. Alphabetical order is used when more than one treatment option is listed within either preferred or alternative therapy. ICS, inhaled corticosteroid; LABA, inhaled long-acting β₂-agonist; SABA, inhaled short-acting β₂-agonist. • The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. • If alternative treatment is used and response is inadequate, discontinue it and use the preferred treatment before stepping up. • If clear benefit is not observed within 4-6 wk and patient/family medication technique and adherence are satisfactory, consider adjusting therapy or alternative diagnosis. • Studies on children 0-4 yr of age are limited. Step 2 preferred therapy is based on Evidence A. All other recommendations are based on expert opinion and extrapolation from studies in older children.

Fig. 2

Classifying asthma severity and initiating treatment in children 0-4 yr of age. Assessing severity and initiating therapy in children who are not currently taking long-term control medication. EIB, exercise-induced bronchospasm. • The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. • Level of severity is determined by both impairment and risk. Assess impairment domain by patient's/caregiver's recall of previous 2-4 wk. Symptom assessment for longer periods should reflect a global assessment such as inquiring whether the patient's asthma is better or worse since the last visit. Assign severity to the most severe category in which any feature occurs. • At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma severity. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past 6 months, or ≥4 wheezing episodes in the past year, and who have risk factors for persistent asthma may be considered the same as patients who have persistent asthma, even in the absence of impairment levels consistent with persistent asthma.

Fig. 3

Assessing asthma control and adjusting therapy in children 0-4 yr of age. EIB, exercise-induced bronchospasm. • The stepwise approach is meant to assist, not replace, the clinical decision making required to meet individual patient needs. • The level of control is based on the most severe impairment or risk category. Assess impairment domain by caregiver's recall of previous 2-4 wk. Symptom assessment for longer periods should reflect a global assessment such as inquiring whether the patient's asthma is better or worse since the last visit. • At present, there are inadequate data to correspond frequencies of exacerbations with different levels of asthma control. In general, more frequent and intense exacerbations (e.g., requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes, patients who had ≥2 exacerbations requiring oral systemic corticosteroids in the past year may be considered the same as patients who have not-well-controlled asthma, even in the absence of impairment levels consistent with not-well-controlled asthma. • Before step up in therapy: Review adherence to medications, inhaler technique, and environmental control. If alternative treatment option was used in a step, discontinue it and use preferred treatment for that step.