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)
Components of control		Well controlled	Not well controlled	Very poorly controlled
Impairment	Symptoms	≤2 days/week	>2 days/week	Throughout the day
	Nighttime awakenings	≤1 time/month	>1 time/month	>1 time/week
	Interference with normal activity	None	Some limitation	Extremely limited
	Short-acting beta₂agonist use for symptom control (not prevention of EIB)	≤2 days/week	>2 days/week	Several times per day
Risk	Exacerbations requiring oral systemic glucocorticoids	0 to 1/year	2 to 3/year	>3/year
Risk	Treatment-related adverse effects	Medication side effects can vary in intensity from none to very 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 treatment		Maintain current treatment. Regular follow-ups every 1 to 6 months. Consider step down if well controlled for at least 3 months.	Step up (1 step) and Reevaluate in 2 to 6 weeks. If no clear benefit in 4 to 6 weeks, consider alternative diagnoses or adjusting therapy. For side effects, consider alternative treatment options.	Consider short course of oral systemic glucocorticoids, Step up (1 to 2 steps) and Reevaluate in 2 weeks. If no clear benefit in 4 to 6 weeks, consider alternative diagnoses or adjusting therapy. For side effects, 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 2 to 4 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. 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.

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.

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Assessing asthma control and adjusting therapy in children 0 to 4 years of age