Asthma in Children Younger Than 12 Years - Initiating Therapy and Monitoring Control

Asthma in children younger than 12 years: Initiating therapy and monitor...
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Asthma in children younger than 12 years: Initiating therapy and monitoring control
Authors
Gregory Sawicki, MD, MPH
Kenan Haver, MD
Section Editors
Robert A Wood, MD
Gregory Redding, MD
Deputy Editor
Elizabeth TePas, MD, MS
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jun 2016. | This topic last updated: May 12, 2015.
INTRODUCTION The treatment of asthma is based upon assessment of severity and, in those already on
therapy, upon assessment of asthma control. Assessing initial asthma severity in children younger than 12 years of
age, determining when to start daily controller therapy, and assessing and monitoring control to determine if
therapy modifications are needed are discussed here.
Our approach to the management of asthma in children is based upon the National Asthma Education and
Prevention Program (NAEPP) Expert panel guidelines, published in 2007, that provide recommendations for the
management of chronic childhood asthma in children aged 0 to 4 years and 5 to 11 years [1]. Their
recommendations for the management of asthma in adolescents and adults are presented separately, as are
detailed discussions about use of controller and quick-relief medications in children younger than 12 years. (See
"Treatment of intermittent and mild persistent asthma in adolescents and adults" and "Treatment of moderate
persistent asthma in adolescents and adults" and "Asthma in children younger than 12 years: Treatment of
persistent asthma with controller medications" and "Asthma in children younger than 12 years: Rescue treatment
for acute symptoms".)
The initial evaluation and diagnosis of asthma in children younger than 12 years of age and the management of
acute asthma exacerbations in children are discussed separately. A general overview of asthma management and
asthma trigger identification and avoidance for patients of all ages are also presented separately. (See "Asthma in
children younger than 12 years: Initial evaluation and diagnosis" and "Acute asthma exacerbations in children:
Emergency department management" and "Acute asthma exacerbations in children: Inpatient management" and
"An overview of asthma management" and "Trigger control to enhance asthma management".)
ASSESSMENT OF SEVERITY IN PATIENTS NOT ON DAILY THERAPY Asthma severity is the intrinsic
intensity of disease. Initial assessment of patients who have confirmed asthma begins with a severity classification
because selection of the type, amount, and scheduling of therapy corresponds to the level of asthma severity. This
assessment is made immediately after diagnosis, or when the patient is first encountered, generally before the
patient is taking some form of long-term controller medication. Asthma severity does not predict the severity of
exacerbations. Even children with mild asthma can have severe exacerbations. (See "Asthma in children younger
than 12 years: Initial evaluation and diagnosis".)
Assessment of asthma severity is made on the basis of components of current impairment and future risk (table
1A-B) [2].
The factors used to determine impairment are:
The frequency of symptoms, nighttime awakenings, and use of short-acting beta agonists for symptom
control (not for prevention of exercise-induced symptoms) in the past two to four weeks, based upon
patient/caregiver recall.
The degree to which symptoms have interfered with normal activity in the past two to four weeks, based
upon patient/caregiver recall.
Spirometry results in children that are able to perform the test.
Risk assessment is primarily based upon the patient/caregiver recall of the number of exacerbations in the past
year that have required treatment with oral glucocorticoids, although the severity of each exacerbation and the
interval since last exacerbation are also taken into consideration.
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The severity is determined by the most severe category measured. As an example, a child who has symptoms
approximately four days per week, uses short-acting beta agonists approximately three days per week, has minor
limitations in normal activities, and has had only one course of oral glucocorticoids for an exacerbation in the past
year (all categorized as "mild"), but has had nighttime awakenings four times a month (categorized as "moderate")
is considered to have asthma of moderate severity.
If the assessment is made during a visit in which the patient is treated for an acute exacerbation, then asking the
patient to recall symptoms and short-acting beta agonist use in the period before the onset of the current
exacerbation will suffice to determine impairment until the following visit. (See "An overview of asthma
management", section on 'Goals of asthma treatment'.)
Assessment of asthma control and asthma severity in children already on controller medication, defined as the
degree of difficulty in achieving asthma control while on daily treatment, are discussed below. (See 'Assessment of
severity in patients on daily therapy' below and 'Assessment of control' below.)
INITIATION OF THERAPY The degree of severity while not on long-term controller medications determines
which "step" or level of initial therapy is needed (table 1A-B and figure 1A-B). Other factors, including the risk of
developing persistent asthma, are also taken into consideration in children under five years of age. Patients with
intermittent asthma require only occasional use of quick-relief medications, whereas patients with persistent
asthma of any severity should be started on daily controller therapy. Our recommendations are in accordance with
the National Asthma Education and Prevention Program (NAEPP) guidelines. How to decide which specific
medication(s) to use is discussed in greater detail separately. (See 'Assessment of severity in patients not on daily
therapy' above and "Asthma in children younger than 12 years: Rescue treatment for acute symptoms" and
"Asthma in children younger than 12 years: Treatment of persistent asthma with controller medications".)
Children 0 to 4 years old Initiation of controller medication for children ages zero to four years is based upon
the severity of symptoms and exacerbations, the frequency of exacerbations, and the risk of development of
subsequent asthma (table 1A).
We recommend initiating controller therapy in children who have had 4 episodes of wheezing in the past year that
lasted more than one day and affected sleep and who have the following risk factors for persistent asthma [3,4]:
One of the following Parental history of asthma, clinician diagnosis of atopic dermatitis, evidence of
sensitization to aeroallergens.
OR
Two of the following Evidence of sensitization to foods, 4 percent peripheral blood eosinophilia, wheezing
apart from colds.
We also suggest the initiation of controller medications for the following children [1]:
Those aged zero to four years who consistently require quick-relief medications more than two days per
week for a period of more than four weeks.
Infants and young children experiencing severe exacerbations less than six weeks apart or those who have
two or more exacerbations requiring systemic glucocorticoids within six months.
Children with intermittent disease who experience severe exacerbations, especially during periods when they
are likely to be exposed to known triggers, such as seasonal pollens or respiratory viruses [5].
Children 5 to 11 years old We agree with the NAEPP recommendations for the initiation of controller
medications for all children ages 5 to 11 years who have persistent asthma defined by symptom frequency, shortacting beta agonist use, impairment of normal activity, and risk for development of future exacerbations (table 1B)
[1].
ASSESSMENT OF SEVERITY IN PATIENTS ON DAILY THERAPY It is more useful to assess degree of
asthma control rather than severity in patients who are already on daily controller asthma treatment. Thus, the
Joint Task Force of the American Thoracic Society and the European Respiratory Society also recommend defining
asthma severity as the degree of difficulty in achieving asthma control while on daily controller treatment in addition
to the components of severity discussed above [2]. (See 'Assessment of severity in patients not on daily therapy'
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above and 'Assessment of control' below.)

Severity may be influenced by the underlying phenotype, environmental and family function factors (including
smoking, stress, and violence), adherence to treatment, drug delivery technique, and comorbidities. As an
example, exposure to violence is associated with more symptom days and higher hospitalization rates [6,7].
Patients with severe asthma can include those who are untreated, who are difficult to treat, and who are maximally
treated but resistant to therapy [8,9]. As an example, children are considered to have severe asthma if they are
poorly controlled on several daily medications or if they are well controlled, but require three controller medications
to maintain asthma control.
ASSESSMENT OF CONTROL The National Asthma Education and Prevention Program (NAEPP) recommends
defining asthma control as the extent to which therapy reduces or eliminates the manifestations of asthma [2]. This
includes evaluation of the components of impairment and risk that are reviewed above, as well as assessment for
treatment-related adverse effects (table 2A-B). Medication side effects may impact adherence. In addition,
significant side effects may necessitate a change in medications even if the patients asthma is well controlled. The
presence of persistent asthma symptoms (impairment domain) is a risk factor for severe asthma exacerbations
(risk domain), although the predictors for each are different [10]. (See 'Assessment of severity in patients not on
daily therapy' above.)
In patients with established asthma, the history obtained at follow-up visits is helpful in determining the adequacy of
control and the risk of future exacerbations. Salient historical points include:
Medications and other therapies
Medical utilization
School attendance and performance
Physical activity
Psychosocial factors
The use of a standardized questionnaire, such as the Asthma Control Test (ACT) or Asthma Control Questionnaire,
facilitates the gathering of this information [11]. The Childhood Asthma Control Test (figure 2) is validated for use in
children aged 4 to 11 years [12]. The Test for Respiratory and Asthma Control in Kids (TRACK) questionnaire is
validated for preschool-aged children. This tool assesses impairment of asthma control (symptom burden, activity
limitations, and rescue use of bronchodilators) and is the first to also assess risk (oral glucocorticoid use in the
past 12 months) [13-15]. The Asthma APGAR (Activities, Persistent triGgers, Asthma medications, Response to
therapy) system includes a patient/parent-completed questionnaire and an algorithm that uses the questionnaire
answers to guide asthma care [16]. The questionnaire collects information on "actionable items," such as asthma
triggers, treatment adherence, inhaler technique, and patient/parent perception of response to treatment, in
addition to assessment of control. The Asthma APGAR system was found to similarly assess asthma control
compared with the ACT. It appears to be a promising tool that provides additional guidance to aid clinicians in
improving asthma care, although further study of this system is needed before it is used routinely in clinical care.
Pulmonary function testing is recommended to assess asthma control (in children able to perform the technique
adequately), in addition to a careful assessment of symptoms and medication use. The available evidence does not
support a role for routine use of fractional exhaled nitric oxide (FeNO) measurement in the diagnosis or monitoring
of asthma in either children or adults, since the addition of FeNO to the usual monitoring for asthma control (table
2A-B) is unlikely to change management [17]. (See "Asthma in children younger than 12 years: Initial evaluation
and diagnosis", section on 'Spirometry' and "Asthma in children younger than 12 years: Initial evaluation and
diagnosis", section on 'Ancillary studies'.)
Suboptimal asthma control is associated with underuse of controller medications [18]. Other potentially modifiable
factors associated with poor control include parents' low expectations that controller medications will improve
asthma symptoms and high levels of worry about competing household priorities, such as jobs, money, safety,
relationships, and health of other family members.
MONITORING AND DOSING ADJUSTMENT Patients should be reevaluated after initiation of controller
therapy to determine its effectiveness. A reasonable interval is two to four weeks for patients diagnosed with
moderate to severe persistent asthma and four to six weeks for children with mild persistent asthma since two- to
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six-week intervals are usually necessary to adequately assess the response to a given intervention (table 1A and
table 1B). The frequency of subsequent visits is determined by the level of asthma control (table 2A and table 2B).
Patients with well-controlled asthma can follow-up every one to six months to determine whether to continue the
same regimen, or step up or step down therapy (figure 1A and figure 1B). In contrast, those with not
well-controlled asthma or very poorly controlled asthma should follow-up in two to six weeks and two weeks,
respectively, to evaluate their response to step-up therapy. (See 'Assessment of control' above.)
Treatment with controller medications may be escalated at any time (table 2A-B and figure 1A-B). Options for
step-up therapy include increasing the dose of inhaled glucocorticoid, adding a long-acting beta agonist (LABA), or
adding a leukotriene-receptor antagonist (LTRA) [19]. Potential issues with each medication (eg, behavioral
changes with montelukast, skeletal effects and adrenal suppression with high-dose inhaled glucocorticoids, and the
boxed warning on the package insert regarding long-term use of LABAs) should be considered and discussed with
patients and their families when choosing step-up therapy. These concerns are discussed in greater detail
separately in the specific drug topics and other topics. Determining which controller therapies to use is also
discussed in greater detail separately. (See "Agents affecting the 5-lipoxygenase pathway in the treatment of
asthma", section on 'Adverse effects' and "Major side effects of inhaled glucocorticoids" and "Beta agonists in
asthma: Controversy regarding chronic use" and "Asthma in children younger than 12 years: Treatment of
persistent asthma with controller medications".)
Adherence with the current regimen should be assessed before escalating therapy. Potentially modifiable factors
associated with underuse of controller medications include absence of a consistent routine for administration of
medications, poor technique administering medications, poor parental understanding and assessment of asthma
control, and parental concerns about the medications [18].
When asthma control has been achieved for at least three months, attempts should be made to reduce the
regimen at one- to two-month intervals as tolerated (table 2A-B and figure 1A-B). Acute exacerbations of asthma
demand more intensive management at any time, including the addition of oral glucocorticoids [20,21]. (See
"Asthma in children younger than 12 years: Rescue treatment for acute symptoms" and "Acute asthma
exacerbations in children: Emergency department management" and "Acute asthma exacerbations in children:
Inpatient management".)
SUMMARY AND RECOMMENDATIONS
Asthma severity is the intrinsic intensity of disease. Initial assessment of patients who have confirmed asthma
begins with a severity classification because selection of the type, amount, and scheduling of therapy
corresponds to the level of asthma severity. This assessment is made immediately after diagnosis, or when
the patient is first encountered, generally before the patient is taking some form of long-term controller
medication. Assessment is made on the basis of components of current impairment and future risk (table
1A-B). (See 'Assessment of severity in patients not on daily therapy' above.)
The degree of severity while not on long-term controller medications determines which "step" or level of initial
therapy is needed (table 1A-B and figure 1A-B). Other factors, including the risk of developing persistent
asthma, are also taken into consideration in children under five years of age. Patients with intermittent
asthma require only occasional use of quick-relief medications, whereas patients with persistent asthma of
any severity should be started on daily controller therapy. (See 'Initiation of therapy' above and "Asthma in
children younger than 12 years: Rescue treatment for acute symptoms" and "Asthma in children younger than
12 years: Treatment of persistent asthma with controller medications".)
We recommend the use of daily controller medications in infants and children younger than 12 years with
persistent asthma of any severity (Grade 1A). (See 'Initiation of therapy' above.)
We also recommend the initiation of controller therapy for children aged zero to four years who had 4
episodes of wheezing in the past year that lasted more than one day and affected sleep, and who have risk
factors for persistent asthma (Grade 1A). (See 'Children 0 to 4 years old' above.)
Additionally, we suggest the use of daily controller therapies for the following children (Grade 2C) (see
'Initiation of therapy' above):
Children with intermittent asthma who experience severe exacerbations, especially during periods when
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they are likely to be exposed to known triggers.

Those aged zero to four years who require reliever medications more than two days per week for a
period of more than four weeks.
Infants and young children experiencing severe exacerbations less than six weeks apart or those who
have two or more exacerbations requiring treatment with systemic glucocorticoids within six months.
In patients on daily controller therapy, asthma severity is defined as the degree of difficulty in achieving
asthma control while on daily treatment in addition to the components of impairment and risk. (See
'Assessment of severity in patients on daily therapy' above.)
Asthma control is defined as the extent to which therapy reduces or eliminates the manifestations of asthma.
This includes evaluation of the components of impairment and risk that are reviewed above, as well as
assessment for treatment-related adverse effects (table 2A-B).
Patients should be reevaluated after initiation of controller therapy to determine its effectiveness. Treatment
with controller medications may be escalated (step up) at any time (table 2A-B and figure 1A-B), although
adherence with the current regimen should be assessed before escalating therapy. Attempts should be made
to reduce the regimen (step down) once asthma control has been achieved for at least three months. The
frequency of follow-up is determined by the severity of asthma and level of control. (See 'Monitoring and
dosing adjustment' above and "Asthma in children younger than 12 years: Treatment of persistent asthma
with controller medications", section on 'Step-up therapy' and "Asthma in children younger than 12 years:
Treatment of persistent asthma with controller medications", section on 'Step-down therapy'.)
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REFERENCES
1. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and
management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no.
08-4051) www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on December 04, 2014).
2. Reddel HK, Taylor DR, Bateman ED, et al. An official American Thoracic Society/European Respiratory
Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and
clinical practice. Am J Respir Crit Care Med 2009; 180:59.
3. Guilbert TW, Morgan WJ, Zeiger RS, et al. Long-term inhaled corticosteroids in preschool children at high
risk for asthma. N Engl J Med 2006; 354:1985.
4. Castro-Rodrguez JA, Holberg CJ, Wright AL, Martinez FD. A clinical index to define risk of asthma in young
children with recurrent wheezing. Am J Respir Crit Care Med 2000; 162:1403.
5. Johnston NW, Mandhane PJ, Dai J, et al. Attenuation of the September epidemic of asthma exacerbations in
children: a randomized, controlled trial of montelukast added to usual therapy. Pediatrics 2007; 120:e702.
6. Sternthal MJ, Jun HJ, Earls F, Wright RJ. Community violence and urban childhood asthma: a multilevel
analysis. Eur Respir J 2010; 36:1400.
7. Wright RJ, Mitchell H, Visness CM, et al. Community violence and asthma morbidity: the Inner-City Asthma
Study. Am J Public Health 2004; 94:625.
8. Bousquet J, Mantzouranis E, Cruz AA, et al. Uniform definition of asthma severity, control, and
exacerbations: document presented for the World Health Organization Consultation on Severe Asthma. J
Allergy Clin Immunol 2010; 126:926.
9. Ldrup Carlsen KC, Hedlin G, Bush A, et al. Assessment of problematic severe asthma in children. Eur
Respir J 2011; 37:432.
10. Wu AC, Tantisira K, Li L, et al. Predictors of symptoms are different from predictors of severe exacerbations
from asthma in children. Chest 2011; 140:100.
11. National Asthma Education and Prevention Program: Expert panel report 3 (EPR3): Guidelines for the
diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH
publication no. 08-4051). www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on February 11,
2010).
12. Liu AH, Zeiger R, Sorkness C, et al. Development and cross-sectional validation of the Childhood Asthma
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Control Test. J Allergy Clin Immunol 2007; 119:817.

13. Murphy KR, Zeiger RS, Kosinski M, et al. Test for respiratory and asthma control in kids (TRACK): a
caregiver-completed questionnaire for preschool-aged children. J Allergy Clin Immunol 2009; 123:833.
14. Chipps B, Zeiger RS, Murphy K, et al. Longitudinal validation of the Test for Respiratory and Asthma Control
in Kids in pediatric practices. Pediatrics 2011; 127:e737.
15. Zeiger RS, Mellon M, Chipps B, et al. Test for Respiratory and Asthma Control in Kids (TRACK): clinically
meaningful changes in score. J Allergy Clin Immunol 2011; 128:983.
16. Rank MA, Bertram S, Wollan P, et al. Comparing the Asthma APGAR system and the Asthma Control Test
in a multicenter primary care sample. Mayo Clin Proc 2014; 89:917.
17. British Guideline on the Management of Asthma. Scottish Intercollegiate Guidelines Network (SIGN); British
Thoracic Society, 2008. http://www.sign.ac.uk/ (Accessed on May 08, 2015).
18. Smith LA, Bokhour B, Hohman KH, et al. Modifiable risk factors for suboptimal control and controller
medication underuse among children with asthma. Pediatrics 2008; 122:760.
19. Castro-Rodriguez JA, Rodrigo GJ. A systematic review of long-acting 2-agonists versus higher doses of
inhaled corticosteroids in asthma. Pediatrics 2012; 130:e650.
20. Canny GJ, Levison H. Childhood asthma: a rational approach to treatment. Ann Allergy 1990; 64:406.
21. Kamada AK, Szefler SJ. Pharmacological management of severe asthma, Marcel Dekker, New York 1996.
Topic 90904 Version 6.0
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GRAPHICS
Classifying asthma severity and initiating treatment in children 0 to 4
years of age
Components of
severity
Classification of asthma severity (0 to 4 years

of age)
Persistent
Intermittent
Mild
Impairment
Symptoms
2 days/week
>2 days/week
Moderate
Daily
but not daily

Nighttime
awakenings
Short-acting
2 days/week
beta 2 agonist
Severe
Throughout
the day
1 to 2
3 to 4
>1
times/month
times/month
time/week
>2 days/week
Daily
Several
but not daily
times per
use for symptom
day
control (not
prevention of
EIB)
Interference
None
with normal
Minor
Some
Extremely
limitation
limitation
limited
activity
Risk
Exacerbations
0 to 1/year
2 exacerbations in six months requiring
requiring oral
oral systemic glucocorticoids, or 4
systemic
wheezing episodes/one year lasting >1
glucocorticoids
day AND risk factors for persistent

asthma
Consider severity and interval since last exacerbation
Frequency and severity may fluctuate over time
Exacerbations of any severity may occur in patients in
any severity category
Recommended step for
Step 1
initiating treatment
Step 2
Step 3 and consider short

course of oral systemic
glucocorticoids
In two to six weeks, depending on severity, evaluate level of

asthma control that is achieved. If no clear benefit is observed in
four to six weeks, consider adjusting therapy or alternative
diagnoses.
Assessing severity and initiating therapy in children who are not currently taking
long-term control medication. 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
two to four weeks. 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, data are inadequate
to correlate frequencies of exacerbations with different levels of asthma severity. For treatment
purposes, patients who had 2 exacerbations requiring oral systemic glucocorticoids in the past
six months, or 4 wheezing episodes in the past year, and who have risk factors for persistent
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asthma may be considered the same as patients who have persistent asthma, even in the absence
of impairment levels consistent with persistent asthma.
EIB: exercise-induced bronchospasm.
Reproduced from: National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines
for the Diagnosis and Management of Asthma. NIH Publication no. 08-4051, 2007.
Graphic 80908 Version 8.0
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Classifying asthma severity and initiating treatment in children 5 to

11 years of age
Components of
severity
Classification of asthma severity (5 to 11 years

of age)
Persistent
Intermittent
Mild
Impairment
Symptoms
2 days/week
>2
Moderate
Daily
days/week
Severe
Throughout
the day
but not daily

Nighttime
2 times/month
awakenings
Short-acting
2 days/week
3 to 4
>1 time/week
Often 7
times/month
but not nightly
times/week
>2
Daily
Several times
beta 2 agonist
days/week
use for symptom
but not daily
per day
control (not
prevention of
EIB)
Interference
None
with normal
Minor
Some
Extremely
limitation
limitation
limited
activity
Lung function
Normal FEV 1
between
FEV 1 80
FEV 1 = 60
FEV 1 <60
percent
to 80
percent
exacerbations
predicted
percent
predicted
FEV 1 >80
FEV 1 /FVC
predicted
FEV 1 /FVC
percent
>80
FEV 1 /FVC
<75
predicted
percent
= 75 to 80
percent
percent
FEV 1 /FVC
>85 percent
Risk
Exacerbations
0 to 1/year
requiring oral
(see footnote)
systemic
glucocorticoids
2/year (see footnote)

Frequency and severity may fluctuate over time for
patients in any severity category
Relative annual risk of exacerbations may be related to
FEV 1
Recommended step for

initiating treatment
Step 1
Step 2
Step 3,
Step 3,
medium
medium
dose-inhaled
dose-inhaled
glucocorticoids
glucocorticoids
option
option, or
Step 4
And consider short course of

oral systemic glucocorticoids
In two to six weeks, evaluate level of asthma control that is
achieved and adjust therapy accordingly
Assessing severity and initiating therapy in children who are not currently taking
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long-term control medication. 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 the
previous two to four weeks and spirometry. Assign severity to the most severe category in which
any feature occurs. At present, data are inadequate to correlate frequencies of exacerbations with
different levels of asthma severity. In general, more frequent and intense exacerbations (eg,
requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate greater underlying
disease severity. For treatment purposes, patients who had 2 exacerbations requiring oral
systemic glucocorticoids in the past year may be considered the same as patients who have
persistent asthma, even in the absence of impairment levels consistent with persistent asthma.
EIB: exercise-induced bronchospasm; FEV 1 : forced expiratory volume in one second; FVC: forced vital
capacity; ICU: intensive care unit.
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Stepwise approach for managing asthma in children 0 to 4 years of

age
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 four to six weeks and patient/family medication technique and adherence are satisfactory,
consider adjusting therapy or alternative diagnosis. Studies on children zero to four years 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.
Alphabetical order is used when more than one treatment option is listed within either
preferred or alternative therapy.
SABA: inhaled short-acting beta 2 agonist; PRN: "as needed"; LABA: inhaled long-acting beta 2 agonist.
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Stepwise approach for managing asthma in children 5 to 11 years of

age
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. Theophylline is a less desirable
alternative due to the need to monitor serum concentration levels. Step 1 and step 2 medications
are based on evidence A. Step 3 inhaled glucocorticoids + adjunctive therapy and inhaled
glucocorticoids are based on evidence B for efficacy of each treatment and extrapolation from
comparator trials in older children and adults. Comparator trials are not available for this age
group. Steps 4 to 6 are based on expert opinion and extrapolation from studies in older children
and adults. Immunotherapy for steps 2 to 4 is based on evidence B for house dust mites, animal
danders, and pollens. Evidence is weak or lacking for molds and cockroaches. Evidence is
strongest for immunotherapy with single allergens. The role of allergy in asthma is greater in
children than in adults. Clinicians who administer immunotherapy should be prepared and
equipped to identify and treat anaphylaxis that may occur.
Alphabetical order is used when more than one treatment option is listed within either
preferred or alternative therapy.
SABA: inhaled short-acting beta 2 agonist; PRN: "as needed"; LTRA: leukotriene receptor antagonist;
LABA: long-acting inhaled beta 2 agonist; EIB: exercise-induced bronchospasm.
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Assessing asthma control and adjusting therapy in children 0 to 4

years of age
Components of control
Classification of asthma control (0 to 4

years of age)
Well controlled
Impairment
Not well
Very poorly
controlled
controlled
Symptoms
2 days/week
>2 days/week
Throughout the day
Nighttime
1 time/month
>1 time/month
>1 time/week
None
Some limitation
Extremely limited
2 days/week
>2 days/week
Several times per
awakenings
Interference with
normal activity
Short-acting beta 2
agonist use for
day
symptom control
(not prevention of
EIB)
Risk
Exacerbations
0 to 1/year
2 to 3/year
>3/year
requiring oral
systemic
glucocorticoids
Treatment-related
Medication side effects can vary in intensity from none to very
adverse effects
troublesome and worrisome. The level of intensity does not

correlate to specific levels of control but should be considered
in the overall assessment of risk.
Recommended action for
Maintain
Step up (one
Consider short
treatment
current
step) and
course of oral
treatment.
Reevaluate in
systemic
Regular
two to six
glucocorticoids,
follow-ups
weeks.
Step up (one to
every one to
If no clear
two steps) and
six months.
benefit in four
Reevaluate in
Consider step
to six weeks,
two weeks.
down if well
consider
If no clear
controlled for at
alternative
benefit in four to
least three
diagnoses or
six weeks,
months.
adjusting
consider
therapy.
alternative
For side effects,
diagnoses or
consider
adjusting
alternative
therapy.
treatment
For side effects,
options.
consider
alternative
treatment
options.
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 two to four weeks.
Symptom assessment for longer periods should reflect a global assessment, such as inquiring
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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 (eg, requiring urgent, unscheduled
care, hospitalization, or ICU admission) indicate poorer disease control. For treatment purposes,
patients who had 2 exacerbations requiring oral systemic glucocorticoids 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 medication, inhaler technique, and environmental control.
- If an alternative treatment option was used in a step, discontinue and use the preferred
treatment for that step.
EIB: exercise-induced bronchospasm; ICU: intensive care unit.
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Assessing asthma control and adjusting therapy in children 5 to 11

years of age
Components of
control
Classification of asthma control (5 to 11 years of

age)
Well controlled
Impairment
Symptoms
Nighttime
Very poorly
Not well controlled
controlled
2 days/week, but
>2 days/week or
not more than once
multiple times on 2
Throughout the day
on each day
days/week
1 time/month
2 times/month
2 times/week
None
Some limitation
Extremely limited
2 days/week
>2 days/week
Several times per
awakenings
Interference
with normal
activity
Short-acting
beta 2 agonist
day
use for symptom

control (not
prevention of
EIB)
Lung function
Risk
FEV 1 or peak
>80 percent
60 to 80 percent
<60 percent
flow
predicted/personal
predicted/personal
predicted/personal
FEV 1 /FVC
best
best
best
>80 percent
75 to 80 percent
<75 percent
Exacerbations
0 to 1/year
2/year (see footnote)
requiring oral
systemic
glucocorticoids
Reduction in
Evaluation requires long-term follow-up
lung growth
Treatment-
Medication side effects can vary in intensity from none to very
related adverse
troublesome and worrisome. The level of intensity does not correlate
effects
to specific levels of control but should be considered in the overall

assessment of risk.
Recommended action for
Maintain current
Step up at least
Consider short
treatment
step.
one step and
course of oral
Regular follow-up
Reevaluate in two
systemic
every one to six
to six weeks.
glucocorticoids,
months.
For side effects,
Step up one to
Consider step
consider
two steps, and
down if well
alternative
Reevaluate in two
controlled for at
treatment options.
weeks.
least three
For side effects,
months.
consider
alternative
treatment options.
The stepwise approach is meant to assist, not replace, the clinical decision-making required to
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meet individual patient needs. The level of control is based on the most severe impairment or risk
category. Assess impairment domain by patient's/caregiver's recall of previous two to four weeks
and by spirometry/or peak flow measures. 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 (eg,
requiring urgent, unscheduled care, hospitalization, or ICU admission) indicate poorer disease
control. For treatment purposes, patients who had 2 exacerbations requiring oral systemic
glucocorticoids in the past year may be considered the same as patients who have persistent
asthma, even in the absence of impairment levels consistent with persistent asthma.
Before step up in therapy:
- Review adherence to medication, inhaler technique, environmental control, and comorbid
conditions.
- If an alternative treatment option was used in a step, discontinue and use the preferred
treatment for that step.
EIB: exercise-induced bronchospasm; FEV 1 : forced expiratory volume in 1 second; FVC: forced vital
capacity; ICU: intensive care unit.
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Childhood Asthma Control Test for children aged 4 to 11 years
Reproduced with permission from: Liu AH, Zeiger R, Sorkness C, et al. Development and cross-sectional
validation of the Childhood Asthma Control Test. J Allergy Clin Immunol 2007; 119:817. Copyright
2007 Elsevier.
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Contributor Disclosures
Gregory Sawicki, MD, MPH Nothing to disclose. Kenan Haver, MD Employment (spouse/partner): Vertex - No
relevant conflict on topic. Robert A Wood, MD Grant/Research/Clinical Trial Support: DBV Technologies [Food
allergy]. Consultant/Advisory Boards: Stallergenes [Allergic rhinitis (Sublingual immunotherapy)]. Gregory
Redding, MD Nothing to disclose. Elizabeth TePas, MD, MS Nothing to disclose.
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be provided
to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate
standards of evidence.
Conflict of interest policy
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