Pediatric Asthma Guidelines

Asthma Basics

A child using a peak flow meter.
A child using a peak flow meter. Photo by 2007 Vincent Iannelli, MD

New Pediatric Asthma Guidelines

Published by the National Asthma Education and Prevention Program, these asthma guidelines were last updated in 2007. The current update presents up-to-date recommendations on medications, monitoring and prevention of asthma. These recommendations reinforce the benefits and safety of inhaled corticosteroids as compared to other preventative medications.

The basics of these guidelines are still that your doctors should use a stepwise approach to managing asthma depending on how severe a child's symptoms are classified, but your pediatrician will also focus on control of those symptoms.

For improving symptoms, a step down, or decrease in regular medications should be made. And there should be a step up for worsening or poorly controlled symptoms until the following goals are met:

  • Minimal or no chronic symptoms during the day or night.
  • Minimal or no exacerbations.
  • No limitations on activities; no school/work/parent's work missed.
  • Peak flows (for older children that are able to do peak flows) greater than 80% of personal best.
  • Minimal use of inhaled short acting beta2-agonists (less than once per day, less than one canister a month).
  • Minimal or no adverse effects from medications.

If your child isn't meeting these goals, you should see your Pediatrician for a reevaluation and to reclassify your child's asthma symptoms and to make adjustments in his treatment regimen.

How Bad Is Your Child's Asthma?

How do you classify your child's asthma? According to the guidelines, your child's asthma can be classified as:

  • Intermittent: Symptoms less than or equal to 2 days a week or 2 nights a month. Peak flows greater than or equal to 80% of your child's personal best, with less than 20% variability in daily peak flow measurements.
  • Mild Persistent: Symptoms more than 2 days a week, but less than once every day or more than 2 nights a month. Peak flows greater than or equal to 80% of your child's personal best, with less than 20-30% variability in daily peak flow measurements.
  • Moderate Persistent: Daily symptoms or symptoms more than 1 night a week. Peak flows that are 60 to 80% of your child's personal best, or more than 30% variability in daily peak flow measurements.
  • Severe Persistent: Continual daytime symptoms and frequent symptoms at night. Peak flows that are less than or equal to 60% of your child's personal best, or more than 30% variability in daily peak flow measurements.

Based on these classifications, your pediatrician should be able to come up with a treatment plan using the preferred treatments of the National Asthma Education and Prevention Program, including:

  • Step 1: No daily (preventative) medications. Short acting inhaled inhaled beta2-agonists can be used as needed for symptoms
  • Step 2: In children under age 5 years, daily use (even if the child is not having any asthma symptoms) of low-dose inhaled corticosteroid (with nebulizer or MDI with holding chamber with or without a face mask or DPI).
  • Step 3: In children under age 5 years, daily use of medium dose inhaled corticosteroids.
  • Step 4: In children under age 5 years, daily use of medium dose inhaled corticosteroids and either long-acting inhaled beta2-agonists or montelukast.
  • Step 5: In children under age 5 years, daily use of high dose inhaled corticosteroids and either long-acting inhaled beta2-agonists or montelukast.
  • Step 6: In children under age 5 years, daily use of high dose inhaled corticosteroids and either long-acting inhaled beta2-agonists or montelukast. An alternative might include oral systemic steroids.

Similar step-wise guidelines exist for children between the ages of 5-11 years and children over age 11 years.

Your child may also need preventative medications if he has had more than 3 episodes of wheezing in the past year that lasted for more than 1 day and affected sleep and who have risk factors for the development of asthma.

Latest Asthma Guidelines

The 2007 guidelines also state that:

  • Antibiotics offer no benefit for asthma exacerbations, except as needed for those patients with fever and purulent sputum, evidence of pneumonia, or suspected bacterial sinusitis.
  • Patients should continue to receive and use a written asthma action plan to help control their asthma symptoms.
  • Patients with moderate or severe persistent asthma should continue to use peak flow monitoring and should have written asthma action plans based on their peak flows.
  • In children under age 5 years, consultation with an asthma specialist is recommended for patients with moderate or severe persistent asthma. Consider consultation for patients with mild persistent asthma.
  • In children over age 5 years and adults, you should get a referral to an asthma specialist if there are difficulties controlling asthma or if step 4 care is required. Referral may be considered if step 3 care is required.

Although written for doctors, understanding the goals of treating asthma and the treatment options should help you become better educated and get your child's asthma under good control. Some questions you should ask about your child with asthmas current treatment regimen:

  • Is your child meeting the goals of the National Asthma Education and Prevention Program?
  • Does his treatment follow those mentioned in the updated Guidelines for the Diagnosis and Management of Asthma? Is he using a preferred treatment? This is especially important if his asthma isn't under good control.
  • Do you have a written asthma action plan?

If your answer to these questions is no, a recheck with your Pediatrician would be a good idea. You might also want to ask if your doctor is familiar with the updated guidelines. If not, then a referral to an asthma specialist might be a good idea.

Is your child taking enough medicine? Use the asthma guidelines to figure out your child's asthma classification and then review the goals and treatment recommendations and compare it to what your child is currently taking. Keep in mind that if your child is in good control and is meeting the goals of the current asthma management guidelines, then no change will likely need to be made, even if he is taking less medication than indicated.

Sources

National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma. July 2007.

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