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Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control

Asthma in children younger than 12 years: Overview of initiating therapy and monitoring control
Literature review current through: Jan 2024.
This topic last updated: Oct 25, 2023.

INTRODUCTION — The treatment of asthma is based upon assessment of severity and, in those already on therapy, upon assessment of asthma control. This topic provides a general outline of 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.

A detailed discussion on our approach to the management of asthma in children, largely consistent with the National Asthma Education and Prevention Program (NAEPP) Expert panel guidelines [1,2] and the Global Initiative for Asthma (GINA) strategy report, is presented separately. Recommendations for the management of asthma in adolescents and adults are also presented separately. (See "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies" and "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms" and "Initiating asthma therapy and monitoring in adolescents and adults" and "Ongoing monitoring and titration of asthma therapies in adolescents and adults".)

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 younger than 12 years: Emergency department management" and "Acute asthma exacerbations in children younger than 12 years: Inpatient management" and "An overview of asthma management" and "Trigger control to enhance asthma management".)

ASSESSMENT OF SEVERITY IN PATIENTS NOT ON DAILY THERAPY

Definition of severity — Asthma severity is the intrinsic intensity of disease. Assessment of asthma severity is made on the basis of components of current impairment and future risk (table 1A-B) [3]. The severity is determined by the most severe category detected. 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. 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".)

Why and when to assess severity — 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 any form of long-term controller medication. 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 severity and asthma control in children already on controller medication is discussed below. (See 'Assessment of severity in patients on daily therapy' below and 'Assessment of control' below.)

Impairment — 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 — 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.

INITIATION OF THERAPY — The degree of severity while not on long-term controller medications determines which "step" or level of initial therapy is needed. Other factors, including the risk of developing persistent asthma, are also taken into consideration in children under five years of age. (See 'Assessment of severity in patients not on daily therapy' above and "Risk factors for asthma" and "Wheezing phenotypes and prediction of asthma in young children" and "Role of viruses in wheezing and asthma: An overview", section on 'Development of asthma'.)

How to decide which specific medication(s) to use and the evidence behind these choices are discussed in detail separately. (See "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms" and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies" and "Treatment of recurrent virus-induced wheezing in young children", section on 'Daily controller therapy'.)

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 [3]. (See 'Assessment of severity in patients not on daily therapy' above and 'Assessment of control' below.)

Severity may be influenced by the underlying phenotype, environmental and social factors (including smoking, fine particulate matter from pollution, stress, and violence), adherence to treatment, drug delivery technique, and comorbidities.

Patients with severe asthma can include those who are untreated, who are difficult to treat, and who are maximally treated but resistant to therapy [4,5]. 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

Definition 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 [1-3]. This includes evaluation of the components of impairment and risk that are reviewed above, as well as assessment for treatment-related adverse effects (table 1A-B). 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 [6]. (See 'Assessment of severity in patients not on daily therapy' above.)

History — 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 (including adherence and adverse effects)

Medical utilization

School attendance and performance

Physical activity

Psychosocial factors

Standardized asthma questionnaires — The use of a standardized questionnaire, such as the Asthma Control Test (ACT), Asthma Control Questionnaire, or Pediatric Asthma Control and Communication Instrument (PACCI), facilitates the gathering of this information [1,2,7,8]. The Childhood ACT (figure 1) is validated for use in children aged 4 to 11 years [9]. 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) [10-12]. The Asthma APGAR (Activities, Persistent triGgers, Asthma medications, Response to therapy) system includes a patient/parent/caregiver-completed questionnaire and an algorithm that uses the questionnaire answers to guide asthma care [13]. The questionnaire collects information on "actionable items," such as asthma triggers, treatment adherence, inhaler technique, and patient/parent/caregiver 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. The PACCI is useful in identifying children with uncontrolled asthma and has both an English and a Spanish version available.

Pulmonary function testing — Spirometry 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 [3,7]. Spirometry can reliably be performed in children beginning at five years of age. Measurement of fractional exhaled nitric oxide (FeNO) is an adjunct test that is typically used for the diagnosis or monitoring of asthma in patients aged five years and older if there is uncertainty in the diagnosis or management after routine assessment (history, physical exam, and spirometry) [2]. Pulmonary function testing in children is discussed in greater detail separately. (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' and "Overview of pulmonary function testing in children".)

Modifiable factors associated with poor control — Suboptimal asthma control is associated with underuse of controller medications [14]. In children who are sensitized to animal dander and house dust mite, environmental control measures to limit these exposures should be initiated and maintained. Children should not be exposed to secondhand cigarette smoking or vaping. Other potentially modifiable factors associated with poor control include parents'/caregivers' low expectations that controller medications will improve asthma symptoms and high levels of worry about competing household priorities, such as jobs, money, safety, relationships, pets, and health of other family/household members. (See "Trigger control to enhance asthma management" and "Allergen avoidance in the treatment of asthma and allergic rhinitis".)

MONITORING AND DOSING ADJUSTMENT

Monitoring — 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 six-week intervals are usually necessary to adequately assess the response to a given intervention (table 1A-B).

The frequency of subsequent visits is determined by the level of asthma control and asthma severity (table 1A-B). Patients with well-controlled asthma typically follow-up every three months to assess response to treatment, but this may be more or less frequent depending upon asthma severity. 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.)

Step-up therapy — Treatment with controller medications may be escalated at any time (table 1A-B). Potential issues with each medication (eg, neuropsychiatric/behavioral changes with montelukast, skeletal growth and adrenal suppression with high-dose inhaled glucocorticoids (table 2)) should be considered and discussed with patients and their families/caregivers when choosing step-up therapy. These concerns are discussed in greater detail separately in the specific drug interactions program included within UpToDate and other topics. Determining which controller therapies to use is also discussed in greater detail separately. (See "Major side effects of inhaled glucocorticoids" and "Beta agonists in asthma: Acute administration and prophylactic use", section on 'Long-term maintenance therapy with LABAs' and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies" and "Antileukotriene agents in the management of asthma", section on 'Adverse effects'.)

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 parent/caregiver understanding and assessment of asthma control, and parent/caregiver concerns about the medications [14]. (See 'Modifiable factors associated with poor control' above.)

Step-down therapy — Step-down therapy is considered when asthma control has been achieved for at least three months (table 1A-B). Factors that affect this decision include severity of asthma, how difficult it was to attain control, and potential triggers. A longer period of control is often preferred before decreasing therapy in a patient with more severe asthma. Step-down therapy is more commonly attempted in the summer but may be delayed at the start of the school year or the onset of the winter viral respiratory infection season. The step-down approach may also proceed more slowly in patients with ongoing exposures to potential triggers such as tobacco smoke or unavoidable pet exposure (eg, home, grandparent's home, daycare, etc) in a child with an animal dander allergy. Patients who have had a reduction in therapy should be reassessed in one to two months. Attempts should be made to reduce the regimen as tolerated in patients who remain in good control.

Acute exacerbations — Acute exacerbations of asthma demand more intensive management at any time, including the addition of oral glucocorticoids [15,16]. (See "Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms" and "Acute asthma exacerbations in children younger than 12 years: Emergency department management" and "Acute asthma exacerbations in children younger than 12 years: Inpatient management".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Asthma in children".)

SUMMARY AND RECOMMENDATIONS

Initial assessment of asthma severity – 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.)

Factors used to decide level of initial 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). Other factors, including the risk of developing persistent asthma, are also taken into consideration in children under five years of age. (See 'Initiation of therapy' above and "Risk factors for asthma" and "Wheezing phenotypes and prediction of asthma in young children" and "Role of viruses in wheezing and asthma: An overview", section on 'Development of asthma'.)

Reassessment of asthma severity on controller therapy – 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.)

Determining asthma control – Asthma control is defined as the extent to which therapy reduces or eliminates the manifestations of asthma (figure 1). This includes evaluation of the components of impairment and risk that are reviewed above, as well as assessment for treatment-related adverse effects (table 1A-B). (See 'Assessment of control' above.)

Monitoring and dose adjustment – 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 1A-B and table 3A-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: Management of persistent asthma with controller therapies", section on 'Step-up therapy' and "Asthma in children younger than 12 years: Management of persistent asthma with controller therapies", section on 'Step-down therapy'.)

  1. National Heart, Lung, and Blood Institute. Guidelines for the Diagnosis and Management of Asthma 2007 (EPR-3). 2012. Available at: www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on August 31, 2021).
  2. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. National Heart, Lung, and Blood Institute, 2020. https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines (Accessed on January 28, 2021).
  3. 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.
  4. 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.
  5. Lødrup Carlsen KC, Hedlin G, Bush A, et al. Assessment of problematic severe asthma in children. Eur Respir J 2011; 37:432.
  6. 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.
  7. Dinakar C, Chipps BE, SECTION ON ALLERGY AND IMMUNOLOGY, SECTION ON PEDIATRIC PULMONOLOGY AND SLEEP MEDICINE. Clinical Tools to Assess Asthma Control in Children. Pediatrics 2017; 139.
  8. Okelo SO, Eakin MN, Patino CM, et al. The Pediatric Asthma Control and Communication Instrument asthma questionnaire: for use in diverse children of all ages. J Allergy Clin Immunol 2013; 132:55.
  9. 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.
  10. 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.
  11. 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.
  12. 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.
  13. 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.
  14. 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.
  15. Canny GJ, Levison H. Childhood asthma: a rational approach to treatment. Ann Allergy 1990; 64:406.
  16. Kamada AK, Szefler SJ. Pharmacological management of severe asthma, Marcel Dekker, New York 1996.
Topic 90904 Version 17.0

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