Stepwise asthma management in infants and children <4 years of age with recurrent wheezing^*

NAEPP^¶ (≤4 years old)		GINA (≤5 years old)		Our approach (<4 years old)
Asthma symptoms/impact	Therapy (all steps include SABA as needed)	Asthma symptoms	Therapy (all steps include SABA as needed)	Therapy (all steps include SABA as needed)
Intermittent: Daytime symptoms ≤2 days/week No nocturnal awakenings No interference with activities Exacerbations treated with OCS ≤1/year	Step 1 A short course of a daily ICS beginning at the start of a respiratory tract infection	Infrequent wheezing with viral infections and little to no symptoms between illnesses	Step 1 Preferred: SABA as needed Alternative: Short course of ICS at onset of viral respiratory illness plus SABA as needed	Step 1 Preferred: A short course of a daily medium-dose ICS beginning at the start of a respiratory tract infection plus SABA as needed Alternative: SABA as needed
Mild persistent: Daytime symptoms >2 but <7 days/week Nocturnal awakenings 1 to 2/month Minor interference with activities Exacerbations treated with OCS ≥2 in 6 months or ≥4 episodes of wheezing lasting more than a day in a year plus risk factors for persistent asthma	Step 2 Preferred: Daily low-dose ICS Alternative: Daily LTRA	Asthma symptoms that require SABA treatment >2 times/week on average for 1 month or ≥3 exacerbations/year or Treated more often than every 6 to 8 weeks with SABA but asthma diagnosis is in question^Δ	Step 2 Preferred: Daily low-dose ICS Alternatives: Daily LTRA or Short course of ICS at onset of viral respiratory illness	Step 2 Preferred: Daily low-dose ICS Alternatives: Daily LTRA or Intermittent low-dose ICS used whenever a SABA is used
Moderate persistent: Daily symptoms Nocturnal awakenings 3 to 4/month Daily SABA use Some activity limitation Exacerbations treated with OCS ≥2 in 6 months or ≥4 episodes of wheezing lasting more than a day in a year plus risk factors for persistent asthma	Step 3^◊ Daily low-dose ICS-LABA or Daily low-dose ICS plus LTRA or Daily medium-dose ICS	Asthma not well controlled on low-dose ICS	Step 3^§ Preferred: Double daily low-dose ICS Alternative: Daily low-dose ICS plus LTRA	Step 3^§ Preferred: Daily low-dose ICS-LABA or Daily low-dose ICS plus LTRA Alternative: Daily medium-dose ICS
Severe persistent: Symptoms throughout the day Nocturnal awakenings >1/week Need for SABA several times/day Extreme limitation in activity Exacerbations treated with OCS ≥2 in 6 months or ≥4 episodes of wheezing lasting more than a day in a year plus risk factors for persistent asthma	Step 4^◊ Preferred: Daily medium-dose ICS-LABA Alternative: Daily medium-dose ICS plus LTRA	Asthma not well controlled on doubled low-dose ICS	Step 4^§ Preferred: Continue doubled daily low-dose ICS and Refer to asthma specialist for evaluation Alternatives: Add-on LTRA or Increase frequency of ICS dosing or Add intermittent ICS for exacerbations	Step 4 Preferred: Daily medium-dose ICS-LABA Alternative: Daily medium-dose ICS plus LTRA
Step-up therapy for severe asthma that is poorly controlled	Step 5 Preferred: Daily high-dose ICS-LABA Alternative: Daily high-dose ICS plus LTRA			Step 5 Preferred: Daily high-dose ICS-LABA Alternative: Daily high-dose ICS plus LTRA
Step-up therapy for severe asthma that is poorly controlled	Step 6 Preferred: Daily high-dose ICS-LABA plus OCS Alternative: Daily high-dose ICS plus LTRA and OCS			Step 6 Preferred: Daily high-dose ICS-LABA plus OCS Alternative: Daily high-dose ICS plus LTRA and OCS

Initial and step-up therapies are noted above. A higher level of initial therapy, with concurrent use of OCS in some cases, may be chosen if the patient presents with an acute exacerbation. Treatment may be stepped down if asthma is well controlled for at least 3 months and is stepped up 1 or 2 steps if asthma is not well controlled or is very poorly controlled. An alternative to stepping up therapy is to first try one of the alternative options in the same step. Before stepping up therapy, inhaler technique, adherence, and exposure to potential triggers (eg, allergens, tobacco smoke exposures) should be assessed along with evaluating for alternative and/or concomitant diagnoses.

NAEPP: National Asthma Education and Prevention Program; GINA: Global Initiative for Asthma; SABA: short-acting beta agonist; OCS: oral corticosteroid (glucocorticoid); ICS: inhaled corticosteroid (glucocorticoid); LTRA: leukotriene receptor antagonist; LABA: long-acting beta agonist.

* Dosing is reviewed in other UpToDate topics and tables on the management of asthma in children.

¶ Theophylline, nedocromil, and cromolyn are not included in the table even though they were included in NAEPP. They are rarely used due to the availability of more effective options.

Δ In these patients, a 3-month trial of therapy is reasonable and will help confirm or refute the diagnosis of asthma.

◊ For children 4 years of age, refer to steps 3 and 4 in the UpToDate table for stepwise asthma management in children aged 5 to 11.

§ Step-up therapy.

References:

National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. 2020 Focused updates to the asthma management guidelines. National Heart, Lung, and Blood Institute, 2020. Available at: https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines (Accessed on December 16, 2020).
Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Available at: www.ginasthma.org (Accessed on October 27, 2022).

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Stepwise asthma management in infants and children <4 years of age with recurrent wheezing*

Stepwise asthma management in infants and children <4 years of age with recurrent wheezing^*