Bronchial Asthma: Stepwise Management in Children (5-12 Years)

Children aged five to twelve years with bronchial asthma should be offered a stepwise management plan. Physicians provide asthma medication at the step more appropriate to the initial severity of the condition. They may advise to move up stepwise to obtain asthma control as necessary or move down stepwise to find and maintain the minimal controlling step. If there is no adequate response to the management, physicians should verify compliance to medication and reconsider the diagnosis of bronchial asthma.

Step 1

Step 1 is recommended for children aged five to twelve years with mild intermittent bronchial asthma. At step 1, physicians recommend using an inhaled short-acting β2 agonist (SABA) as necessary.

If there is no adequate control with step 1,

It is better to check inhaler technique and improve it.
It is better to check compliance to the treatment.
It is recommended moving to step 2, if compliance to the medication and inhaler technique are satisfactory.

Step 2

Step 2 is appropriate to children, who cannot control asthma with step 1, as a regular preventer treatment. Physicians will add inhaled steroid like Mometasone furoate, Budesonide, Beclometasone dipropionate, or Fluticasone propionate 200-400 µg/day. A dose of 200 µg is adequate for many children as the starting dose. Other preventer medication (e.g. leukotriene receptor blocker/antagonist like Zafirlukast or Montelukast) can be offered, if inhaled steroid can’t be used. Physicians decide the appropriate dose of medication according to the initial severity of bronchial asthma.

If there is no adequate control with step 2,

It is better to check inhaler technique and improve it.
It is better to check compliance to the treatment.
It is recommended moving to step 3, if compliance to the medication and inhaler technique are satisfactory.

Consider to move down to step 1, if disease control is satisfactory with step 2.

Step 3

Step 3 is offered to children, who have no adequate asthma control with step 2. Physicians will ask to add inhaled long-acting β2 agonist (LABA) like Salmeterol or Formoterol as an initial add-on medication. They will re-assess control of the condition with LABA. If it is adequate to manage bronchial asthma, physicians will recommend continuing the same medication. If there are some benefits from LABA but bronchial asthma control is not satisfactory, it is recommended continuing LABA and raising the dose of inhaled steroid to 400 µg/day (if the patient is not already on this dose). If there is no response to LABA at all, discontinue LABA and increase the steroid inhalation to 400 µg/day. If it is still difficult to achieve asthma control, physicians will consider adding trial of other medications such as Theophylline sustained-release (SR) or leukotriene receptor antagonists/blockers (Zafirlukast or Montelukast).

If there is no adequate control with step 3,

It is better to check inhaler technique and improve it.
It is better to check compliance to the treatment.
It is recommended moving to step 4, if compliance to the medication and inhaler technique are satisfactory.

Consider to move down to step 2, if disease control is satisfactory with step 3.

Step 4

Step 4 is provided to patients, who have persistent poor control and cannot control the condition with step 3. Patients should be advised to raise the dose of inhaled steroid up to 800 µg/day.

If there is no adequate control with step 4,

It is better to check inhaler technique and improve it.
It is better to check compliance to the treatment.
It is recommended moving to step 5, if compliance to the medication and inhaler technique are satisfactory.

Consider to move down to step 3, if disease control is satisfactory with step 4.

Step 5

Step 5 is recommended when asthma control cannot be achieved with step 4. Physicians will offer daily steroid tablets in lowest dose providing sufficient control. They recommend keeping up high dose of inhaled steroid (800 µg/day) as well as a referral to a respiratory paediatrician.

If there is no adequate control with step 5,