Asthma in children

Question 1

Key checkpoints

Answer 1

Seek specialist advice for children under 6 m

Bronchodilators, inhaled or oral, are ineffective under 12 mths

The delivery method is a problem in children

In the very young (e.g. 1–2 yrs) a spacer with a face mask can deliver the aerosol medication

It is recommended to wash spacers in soapy water or detergent and leave to dry on a towel every 7 d

The PEF rate should be measured in all asthmatic children older than 6 yrs. It is unreliable before 7 yrs.

Turbuhaler is usually not practical under 7–8 yrs

Question 2

Prophylaxis in children

Answer 2

The non-steroid medication montelukast (oral) and SCG or nedocromil by inhalation are the prophylactic drugs in childhood chronic asthma of mild to moderate severity.

If there is no clinical response to the cromolyns, use inhaled cortico steroids, but the risks versus benefits must always be considered.

Aim for a maintenance of 100–250 mcg of beclomethasone dipropionate or equivalent (higher doses best with specialist co-care), which keeps the child symptom-free.

One or two attacks only is not an indication to start corticosteroids.

Leukotriene antagonists (e.g. montelukast 5 mg chewable tablet nocte) in those aged 6–14 yrs is another option.

Question 3

Viral-induced preschool wheeze

Answer 3

If a preschool aged child presents with a viral-induced wheeze, especially if a severe wheeze or with a history of asthma, give oral prednisolone.

Question 4

Classifying asthma severity and initiating treatment in children 0-4 yr of age.

Answer 4

Question 5

Stepwise interval management plan for children

Answer 5

Mild—infrequent episodic

• attack not severe
• >6–8 wks apart

—> SABA prn (preferably via a spacer)

Moderate—frequent episodic

• attack <6 wks apart
• av. every 4–6 wks
• attacks more troublesome

—> SABA prn and

• trial of montelukast esp. 2–5 yrs: 4 mg (o) nocte 6–14 yrs: 5 mg (o) nocte
• or cromolyn
• or ICS—min effective dose, e.g. beclomethasone 100–200 mcg/d, budesonide 200–400 mcg/d

Severe—persistent asthma

• symptoms most days
• nocturnal asthma >1 per wk
• multiple ED visits

—> SABA prn and

• •ICS, e.g. beclomethasone 100–200 mcg bd
• •consider combination LABA + ICS ± ipratropium bromide (nebuliser)
• •oral prednisolone (when required)