Classification and Treatment of Infants
and Small Children < age 5

Treatment of asthma in young children starts with finding out how severe their asthma is. Once this is done, treatment can be managed using a stepwise approach, such as the one from the National Institutes of Health (NIH) shown below, as a guide.

Classifying Asthma Severity in Children

**Remember, for any child with asthma, the severity of the disease can change over time.**

When Should Asthma Severity be Classified?

1. Before therapy is started
• Classify severity according to the clinical features of the child’s asthma
2. Before optimal therapy is attained
• If the child is taking medication, but optimal control of the child’s asthma has not yet been achieved, classify severity according to the clinical features of the child’s asthma, as indicated in the chart below.
3. After optimal therapy is attained
• The child’s asthma severity can be classified according to the level of treatment needed to maintain control. For example:

For mild intermittent asthma, no daily medication is needed.

However, the use of short-acting b₂-agonist more than two times per week may indicate the need to start long-term control medication.

For mild persistent asthma, one daily long-term control medication is necessary. For moderate persistent asthma, inhaled corticosteroids with or without additional long-term control medications are indicated.

For severe persistent asthma, multiple long-term control medications are required, including high-dose inhaled corticosteroids and, if needed, oral corticosteroids.

Classification of Asthma Severity: Clinical Features Before Treatment

• Children should be assigned to the most severe step in which any feature occurs. Clinical features for individual children may overlap across steps.
• Percent predicted values for forced expiratory volume in 1 second (FEV₁) and percent of personal best for peak expiratory flow (PEF) are relevant for children 4 years old or older who can use these devices. In very young children, spirometry may not be a reliable measure of changes in lung function either due to the child's ability to perform the test reliably or spirometry's lack of sensitivity in this age group. Pulmonary function testing appropriate for the young child may be provided in a specialty practice. Current literature addresses the use of tests such as airway resistance measurements in infants and young children to improve the sensitivity of the results.*
• Children with more than 2 episodes of asthma symptoms per week have moderate-to-severe persistent asthma.
• Children with viral-induced wheezing may have severe episodes with complete resolution between episodes, and may remain symptom free for months.
• Persistent asthma may become more severe or less severe over time. Children at any level of severity of chronic asthma can have mild, moderate, or severe exacerbations of asthma. Some children with intermittent asthma have severe and life-threatening attacks separated by long periods of normal lung function and no symptoms.

Treating Children < age 5 for Asthma

With an accurate diagnosis and classification, the child’s asthma can then be managed using best practices and a stepwise approach. To learn more about the medications referred to, click here.

• Treatment of acute or chronic wheezing or cough should follow best practices, including the stepwise approach presented in the NIH stepwise guide below.
• In general, physicians should do the following when infants and young children consistently require treatment for symptoms more than two times per week:
• Prescribe daily inhaled anti-inflammatory medication (inhaled steroids, cromolyn, or nedocromil) as long-term control asthma therapy. A trial of cromolyn or nedocromil is often given to patients with mild persistent asthma due to the safety profile of these medications.
• Monitor the response to therapy carefully (e.g., frequency of symptoms over two to four weeks).
• If benefits are sustained for at least 3 months, a step down in therapy should be attempted.

Quick-Relief for All Patients

Bronchodilator as needed for symptoms: Short-acting inhaled b₂-agonist by nebulizer (0.05 mg/kg in 2-3 cc of saline) or inhaler with face mask and spacer (2-4 puffs; for exacerbations, repeat every 20 minutes for up to 1 hour) or oral b₂-agonist.

With Viral Respiratory Infection

Use short-acting inhaled b₂-agonist q 4 to 6 hours up to 24 hours (longer with physician consult) but, in general, if repeated more than once every 6 weeks, consider moving to next step up. Consider oral steroids if the exacerbation is moderate to severe or at the onset of the infection if the patient has a history of severe exacerbations.

NOTES:

• At the onset, give therapy at a higher level to achieve rapid control and then step down to the minimum therapy needed to maintain control. A higher level of therapy can be accomplished by either adding a course of oral steroids to inhaled steroids, cromolyn, or nedocromil or using a higher dose of inhaled steroids.
• If control is not achieved with initial therapy (e.g. within 1 month), the step selected, the therapy in the step, and possibly the diagnosis should be reevaluated.
• A course of oral steroids (prednisolone) may be needed at any time and step.
• Referral to an asthma specialist for consultation or comanagement is recommended for patients requiring step 3 or 4 care. Referral may be considered for step 2 care.

Poor Asthma Control

1. Assess Reasons for Poor Asthma Control – ICE
• Inhaler technique – Check patient’s technique.
• Compliance – Ask when and how much medication the patient is taking.
• Environment - Ask patient/parent if something in his or her environment has changed.

Is there environmental tobacco smoke in the home? Find out about cotinine levels, which can help track exposure to tobacco smoke and its toxic constituents using a saliva, blood or urine test.

You may also want to consider an alternative diagnosis. Assess patient for presence of other upper respiratory disease or alternative diagnosis.

2. Consider Increasing Long-Term Medications

It may be necessary to temporarily increase anti-inflammatory medication to regain control of a patient’s asthma. This will depend on the frequency of the following events, the reasons for poor control, and the clinician’s judgment.

• Patient is awakened at night with symptoms
• They have an urgent care visit
• Patient has increased need for short-acting inhaled b₂-agonists (excludes use for upper respiratory viral infections and exercise-induced bronchospasm) OR
• At step 1: Used short-acting inhaled b₂–agonists more than two times in a week
• At steps 2-3: Used short-acting inhaled b₂-agonists more than three to four times a day OR used this medication on a daily basis for a week or less
• Patient used more than one canister of short-acting inhaled b₂-agonist in one month

Medication Delivery in Young Children

Medication delivery devices should be selected based on the child’s ability to use them well.

Children aged 2 or less — nebulizer therapy is preferred for administering cromolyn or high doses of short-acting inhaled b₂-agonists. A metered-dose inhaler (MDI) with a spacer/valved-holding chamber that has a face mask may be used to take inhaled steroids.

Children 3 to 5 years of age — MDI plus spacer/valved-holding chamber may be used by many children of this age. If the desired therapeutic effects are not achieved, a nebulizer or an MDI plus spacer/valved-holding chamber with a face mask may be required.

Adapted from the Guidelines for the Diagnosis and Management of Asthma, National Asthma Education and Prevention Program, National Institutes of Health, 1997.

*PFT References

PF Standards

1. American Thoracic Society. Lung function testing selection of reference values and interpretation strategies: a statement of the American Thoracic Society. Am Rev Respir Dis 1991; 144:1202-1218.
2. American Thoracic Society. Guidelines for the evaluation of impairment/disability in patients with asthma. Am Rev Respir Dis 1993; 147:1056-1061.
3. American Thoracic Society. Standardization of spirometry: 1994 update. Am J Respir Crit Care Med 1995; 152:1107-1136.
4. American Thoracic Society Pulmonary Laboratory Management and Procedure Manual. New York, NY; American Thoracic Society; 1998.

Young Children and PF

1. Krowka MJ, Enright PL, Rodarte JR, Hyatt RE. Effect of effort on the measurement of forced expiratory volume in one second. Am Rev Respir Dis 1987;136(4):829-833.
2. Avery ME, and Fletcher BD. The Lung and Its Disorders in the Newborn Infant. 3rd Ed. Philadelphia, W.B. Saunders Company, 1974.
3. Blonshine SB, Honicky RE, King KL. Achieving American Thoracic Society performance standards for spirometry, lung volumes, and airway mechanics in pediatric asthmatics. (abstract) Respiratory Care 2000