Asthma Management Handbook

Provisional diagnosis and treatment trial for asthma in a child aged 6 years and over

Recommendations

A provisional diagnosis of asthma can be made if the child has (all of):

  • wheezing accompanied by breathing difficulty or cough
  • other features that increase the probability of asthma such as a history of allergic rhinitis, atopic dermatitis or a strong family history of asthma and allergies
  • no signs or symptoms that suggest a serious alternative diagnosis
  • clinically important response to bronchodilator demonstrated on spirometry performed before and after short-acting beta2 agonist (if child is able to perform spirometry).

Notes

If reliable equipment and appropriately trained staff are available, spirometry can be performed in primary care. If not, refer to an appropriate provider such as an accredited respiratory function laboratory.

Most children aged 6 and older can perform spirometry reliably.

Airflow limitation is defined as reversible (i.e. bronchodilator response is clinically important) if FEV1 increases by ≥12%.

If spirometry does not demonstrate a clinically important response to bronchodilator, the test can be repeated when the child has symptoms.

Table. Findings that increase or decrease the probability of asthma in children

Asthma more likely

Asthma less likely

More than one of:

  • wheeze
  • difficulty breathing
  • feeling of tightness in the chest
  • cough

Any of:

  • symptoms only occur when child has a cold, but not between colds
  • isolated cough in the absence of wheeze or difficulty breathing
  • history of moist cough
  • dizziness, light-headedness or peripheral tingling
  • repeatedly normal physical examination of chest when symptomatic
  • normal spirometry when symptomatic (children old enough to perform spirometry)
  • no response to a trial of asthma treatment
  • clinical features that suggest an alternative diagnosis

AND

Any of:

  • symptoms recur frequently
  • symptoms worse at night and in the early morning
  • symptoms triggered by exercise, exposure to pets, cold air, damp air, emotions, laughing
  • symptoms occur when child doesn’t have a cold
  • history of allergies (e.g. allergic rhinitis, atopic dermatitis)
  • family history of allergies
  • family history of asthma
  • widespread wheeze heard on auscultation
  • symptoms respond to treatment trial of reliever, with or without a preventer
  • lung function measured by spirometry increases in response to rapid-acting bronchodilator
  • lung function measured by spirometry increases in response to a treatment trial with inhaled corticosteroid (where indicated)

Sources

British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the management of Asthma. A national clinical guideline. BTS/SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline

Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic Guidelines Limited, Melbourne, 2009.

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Table. Conditions that can be confused with asthma in children

Conditions characterised by cough

Pertussis (whooping cough)

Post-viral cough

Cystic fibrosis

Airway abnormalities (e.g. tracheobronchomalacia)

Protracted bacterial bronchitis in young children

Habit-cough syndrome

Conditions characterised by wheezing

Upper airway dysfunction

Inhaled foreign body causing partial airway obstruction

Tracheobronchomalacia

Conditions characterised by difficulty breathing

Hyperventilation

Anxiety

Breathlessness on exertion due to poor cardiopulmonary fitness

Upper airway dysfunction

Source

Weinberger M, Abu-Hasan M. Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma. Pediatrics 2007; 120: 855-64. Available from: http://pediatrics.aappublications.org/content/120/4/855.full

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Table. Findings that require investigations in children

Finding

Notes

Persistent cough that is not associated with wheeze/breathlessness or systemic disease

 Unlikely to be due to asthma

Onset of signs from birth or very early in life

Suggests cystic fibrosis, chronic lung disease of prematurity, primary ciliary dyskinesia, bronchopulmonary dysplasia, congenital abnormality

Family history of unusual chest disease

Should be enquired about before attributing all the signs and symptoms to asthma

Severe upper respiratory tract disease (e.g. severe rhinitis, enlarged tonsils and adenoids or nasal polyps)

Specialist assessment should be considered

Crepitations on chest auscultation that do not clear on coughing

Suggest a serious lower respiratory tract condition such as pneumonia, atelectasis, bronchiectasis

Unilateral wheeze

Suggests inhaled foreign body

Systemic symptoms (e.g. fever, weight loss, failure to thrive)

Suggest an alternative systemic disorder

Feeding difficulties, including choking or vomiting

Suggests aspiration – specialist assessment should be considered

Inspiratory upper airway noises (e.g. stridor, snoring)

Acute stridor suggests tracheobronchitis (croup)

Persistent voice abnormality

Suggests upper airway disorder

Finger clubbing

Suggests cystic fibrosis, bronchiectasis

Chronic (>4 weeks) wet or productive cough

Suggests cystic fibrosis, bronchiectasis, chronic bronchitis, recurrent aspiration, immune abnormality, ciliary dyskinesia

Focal (localised) lung signs

Suggests pneumonia

Nasal polyps in child under 5 years old

Suggests cystic fibrosis

Severe chest deformity

Harrison’s Sulcus and Pectus Carinatum can be due to uncontrolled asthma, but severe deformity suggests an alternative diagnosis

Obvious breathing difficulty, especially at rest or at night

Specialist assessment should be considered

Recurrent pneumonia

Specialist assessment should be considered

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Assess and record frequency and severity of symptoms, including flare-ups.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

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Trial treatment with short-acting beta2 agonist reliever as needed, or with regular preventer (and reliever as needed), as indicated.

Table. Classification of asthma and indications for initiating preventer treatment in children aged 6–11

 

 

 

 

 

 

Severity of flare-ups

Average frequency of flare-ups and symptoms between flare-ups

Infrequent intermittent
Flare-ups every 6 weeks or less and no symptoms between flare-ups

Frequent intermittent
Flare-ups more than once every 6 weeks and no symptoms between flare-ups

Persistent
Between flare-ups (any of):

  • Daytime symptoms‡ more than once per week
  • Night-time symptoms‡ more than twice per month
  • Symptoms restrict activity or sleep

Mild flare-ups

(almost always managed with salbutamol in community)

 

Not indicated

 

Consider

 

Indicated

Moderate–severe flare-ups

(>2 in past year requiring ED or oral corticosteroids)

 

Consider

 

Indicated

 

Indicated

Life-threatening flare-ups

(require hospitalisation or PICU)

 

Indicated

 

Indicated

 

Indicated

 

Preventer should be started as a treatment trial. Assess response after 4–6 weeks and review before prescribing long term.

ED: emergency department

Indicated: Prescribe preventer and monitor as a treatment trial. At follow-up, discontinue if ineffective

Not indicated: Preventer is unlikely to be beneficial

Consider prescribing preventer according to overall risk for severe flare-ups

‡ Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action by parents/carers and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).

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Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (microg)

Low

High

Beclometasone dipropionate

100–200

>200 (maximum 400)

Budesonide

200–400

>400 (maximum 800)

Ciclesonide

80–160

>160 (maximum 320)

Fluticasone propionate

100–200

>200 (maximum 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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Assess response after 4–6 weeks and review before prescribing long term. At this follow-up, discontinue if ineffective.

See: Reviewing initial treatment in children aged 6 years and over

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

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If cough does not respond to a treatment trial with a preventer, cease treatment instead of increasing the dose.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

Repeat the treatment trial if the effect on symptoms is unclear.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Classification of symptom patterns in children

The pattern and severity of symptoms in a child with asthma or preschool wheeze is a guide to initial treatment.

Table. Classification of preschool wheeze and indications for preventer treatment in children aged 1–5

Severity of flare-ups

Frequency of symptoms

Symptoms every 6 months or less

Symptoms every 3–4 months

Symptoms every 4–6 weeks

Symptoms at least once per week

Mild flare-ups

(managed with salbutamol in community)

Not indicated

Not indicated

Consider

Indicated

Moderate–severe flare-ups

(require ED care/oral corticosteroids)

Indicated

Indicated

Indicated

Indicated

Life-threatening flare-ups

(require hospitalisation or PICU)

Indicated

Indicated

Indicated

Indicated

PICU: paediatric intensive care unit; ED: emergency department

Indicated: Prescribe preventer and monitor as a treatment trial. Discontinue if ineffective.

Not indicated: Preventer is unlikely to be beneficial

Consider prescribing preventer according to overall risk for severe flare-ups

Symptoms: wheeze, cough or breathlessness. May be triggered by viral infection, exercise or inhaled allergens

Flare-up: increase in symptoms from usual day-to-day symptoms (ranging from worsening asthma over a few days to an acute asthma episode)

Preventer options: an inhaled corticosteroid (low dose) or montelukast

[!] Advise parents/carers about potential adverse behavioural and/or neuropsychiatric effects of montelukast

Notes:
Preventer medication is unlikely to be beneficial in a child whose symptoms do not generally respond to salbutamol

In children taking preventer, symptoms should be managed with a short-acting inhaled beta2 agonist reliever (e.g. when child shows difficulty breathing).

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Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer

Category

Pattern and intensity of symptoms (when not taking regular treatment)

Infrequent intermittent asthma †

Symptom-free for at least 6 weeks at a time (flare-ups up to once every 6 weeks on average but no symptoms between flare-ups)

Frequent intermittent asthma

Flare-ups more than once every 6 weeks on average but no symptoms between flare-ups

Persistent asthma

Mild

FEV1 ≥80% predicted and at least one of:

  • Daytime symptoms more than once per week but not every day
  • Night-time symptoms more than twice per month but not every week

Moderate

Any of:

  • FEV1 <80% predicted
  • Daytime symptoms daily
  • Night-time symptoms more than once per week
  • Symptoms sometimes restrict activity or sleep

Severe

Any of:

  • FEV1 ≤60% predicted
  • Daytime symptoms‡ continual
  • Night-time symptoms frequent
  • Flare-ups frequent
  • Symptoms frequently restrict activity or sleep

† It may not be appropriate to make the diagnosis of asthma in children aged 6 or older who wheeze only during upper respiratory tract infections. These children can be considered to have episodic (viral) wheeze.

‡ Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action by parents and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).

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Table. Classification of asthma and indications for initiating preventer treatment in children aged 6–11

 

 

 

 

 

 

Severity of flare-ups

Average frequency of flare-ups and symptoms between flare-ups

Infrequent intermittent
Flare-ups every 6 weeks or less and no symptoms between flare-ups

Frequent intermittent
Flare-ups more than once every 6 weeks and no symptoms between flare-ups

Persistent
Between flare-ups (any of):

  • Daytime symptoms‡ more than once per week
  • Night-time symptoms‡ more than twice per month
  • Symptoms restrict activity or sleep

Mild flare-ups

(almost always managed with salbutamol in community)

 

Not indicated

 

Consider

 

Indicated

Moderate–severe flare-ups

(>2 in past year requiring ED or oral corticosteroids)

 

Consider

 

Indicated

 

Indicated

Life-threatening flare-ups

(require hospitalisation or PICU)

 

Indicated

 

Indicated

 

Indicated

 

Preventer should be started as a treatment trial. Assess response after 4–6 weeks and review before prescribing long term.

ED: emergency department

Indicated: Prescribe preventer and monitor as a treatment trial. At follow-up, discontinue if ineffective

Not indicated: Preventer is unlikely to be beneficial

Consider prescribing preventer according to overall risk for severe flare-ups

‡ Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action by parents/carers and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).

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For children already taking regular preventer treatment, adjustments to the treatment regimen are based on finding the lowest dose of medicines that will maintain good control of symptoms.

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Cough and asthma in children

Relationship of cough to asthma in children

  • Misdiagnosis of nonspecific cough as asthma can result in overtreatment in children.
  • Cough can indicate the possibility of a serious underlying illness and warrant further assessment and investigations.1

Table. Red flags for cough in children

Wet or productive cough lasting more than 4 weeks

Obvious difficulty breathing, especially at rest or at night

Systemic symptoms: fever, failure to thrive or poor growth velocity

Feeding difficulties (including choking or vomiting)

Recurrent pneumonia

Inspiratory stridor (other than during acute tracheobronchitis)

Abnormalities on respiratory examination

Abnormal findings on chest X-ray

‘Clubbing’ of fingers

Source

Gibson PG, Chang AB, Glasgow NJ et al., CICADA: Cough in Children and Adults: Diagnosis and Assessment. Australian cough guidelines summary statement. Med J Aust, 2010; 192: 265-71. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20201760

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Chronic cough (cough lasting more than 4 weeks) without other features of asthma is unlikely to be due to asthma.1

Cough is a frequent symptom in children with asthma, but may have a different mechanism from other symptoms of asthma (e.g. wheeze, chest tightness or breathlessness). Children who have recurrent cough, but do not wheeze, are unlikely to have asthma.2 A very small minority of children with recurrent nocturnal cough, but no other asthma symptoms, may be considered to have a diagnosis of atypical asthma.2  This diagnosis should be only made in consultation  with a paediatric respiratory physician.

In children with no abnormalities detected on physical examination, chest X-ray or spirometry, and no wheezing or breathlessness, chronic cough is most likely:1

  • due to protracted bacterial bronchitis (resolves with 2–6 weeks’ treatment with antibiotics)1
  • post-viral (resolves with time)
  • due to exposure to tobacco smoke and other pollutants.1

Frequency of cough reported by parents correlates poorly with frequency measured using diary cards or by audio recording monitors.3

0-5 years

Most cases of coughing in preschool children are not due to asthma:

  • Recurrent cough in preschool children, in the absence of other signs, is most likely due to recurrent viral bronchitis. Cough due to viral infection is unresponsive to bronchodilators and preventers such as montelukast, cromones or inhaled corticosteroids.
  • Children attending day care or preschool can have a succession of viral infections that merge into each other,3 giving the false appearance of chronic cough (cough lasting more than 4 weeks).

In preschool-aged children, cough may be due to asthma when it occurs during episodes of wheezing and breathlessness or when the child does not have a cold.

6 years and over

Chronic cough may be due to asthma if the cough is episodic and associated with other features of asthma such as expiratory wheeze, exercise-related breathlessness, or airflow limitation objectively demonstrated by spirometry (particularly if responsive to a bronchodilator).1

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Short-acting beta-2 agonist relievers for children: 6 years and over

Inhaled short-acting beta2 agonists is the major class of bronchodilators used for relief of symptoms in asthma.4

Children with well-controlled asthma need little or no reliever (on no more than 2 days per week).

Increased use of short-acting beta2 agonists for relief of asthma symptoms, especially daily use, indicates deterioration of asthma control.

Dispensing of 3 or more canisters in a year (average 1.6 puffs per day) is associated with increased risk of flare-ups.1 Dispensing 12 or more canisters in a year (average 6.6 puffs per day) is associated with increased risk of asthma death.2

Table. Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen)

Good control Partial control Poor control

All of:

  • Daytime symptoms ≤2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • No limitation of activities
  • No symptoms§ during night or when wakes up
  • Need for SABA reliever# ≤2 days per week

Any of:

  • Daytime symptoms >2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • Any limitation of activities*
  • Any symptoms during night or when wakes up††
  • Need for SABA reliever# >2 days per week

Either of:

  • Daytime symptoms >2 days per week (lasting from minutes to hours or recurring, and partially or fully relieved by SABA reliever)
  • ≥3 features of partial control within the same week

SABA: short-acting beta2 agonist

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including doses taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

​* e.g. wheeze or breathlessness during exercise, vigorous play or laughing

†† e.g. waking with symptoms of wheezing or breathing problems

Notes:

Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes should also be assessed and taken into account in management.

Validated questionnaires can be used for assessing recent symptom control:
Test for Respiratory and Asthma Control in Kids (TRACK) for children < 5 years
Childhood Asthma Control Test (C-ACT) for children aged 4–11 years

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Inhaled corticosteroids for children: efficacy

Role in treatment asthma in children

The effectiveness of ICS in children appears to depend on several factors including the child’s age, which triggers are causing symptoms, wheezing phenotype, tobacco smoke exposure and genotype.5 Overall, inhaled corticosteroids seem to be more effective in older children and those with more severe disease.6

Early introduction of inhaled corticosteroid for children with recurrent wheeze does not prevent airway remodelling, improve long-term lung function or prevent the onset of persistent asthma, according to current evidence from long-term randomised controlled clinical trials in preschool children and school-aged children with intermittent or mild persistent asthma.6

Current evidence does not support planned seasonal use of inhaled corticosteroids in children not taking preventer at other times.7

Children aged 1–5 years

Intermittent wheeze/asthma

In preschool children who only have wheezing episodes with viral respiratory infections, limited available evidence suggests that regular treatment with inhaled corticosteroids does not reduce the risk of hospitalisation, flare-ups that require oral corticosteroid use, or reduce the frequency and duration of acute episodes.58 Inhaled corticosteroid treatment does not reduce these children’s risk of developing persistent wheeze by age 6 years.9

Persistent wheeze/asthma

In preschool children who have episodes of wheezing from time to time, but also cough and wheezes at other times when they do not have a viral cold (e.g. when cries, plays or laughs), regular inhaled corticosteroids are moderately effective in controlling symptoms, though less effective than in older children.9 When wheeze improves markedly during a short treatment trial (e.g. 3 months), it is not possible to tell whether improvement was due to the treatment or spontaneous resolution of symptoms.9 However, this can be clarified by stopping inhaled corticosteroid treatment, monitoring symptoms, and re-starting.

In infants and preschoolers with persistent wheezing or asthma of at least 6 months’ duration, regular treatment with inhaled corticosteroids improves wheezing, asthma symptoms and lung function, and reduces flare-ups.610 

Children aged 6 years and over

Most clinical trials of regular inhaled corticosteroid treatment in children have been conducted among children with asthma symptoms every week or more often (‘persistent asthma’).6 

Beclometasone dipropionate, budesonide, ciclesonide and fluticasone propionate have all been shown to be effective in children. There have been relatively fewer studies of ciclesonide in children,6 but, overall, randomised clinical trials show that it is equally effective as budesonide or fluticasone propionate in improving asthma symptoms and reducing flare-ups.11 In some studies, ciclesonide was associated with less adrenal suppression or height than comparator inhaled corticosteroids.11

In a study of school-aged children with more than 2 days per week with symptoms, night waking more than twice per month due to asthma symptoms, or needing regular preventer, regular low-dose daily inhaled corticosteroid treatment reduced the rate of flare-ups that require treatment with oral corticosteroids, compared with no regular preventer treatment and as-needed short-acting beta2agonist for wheezing episodes.12

In a study of children aged 4–11 years with asthma diagnosed within the previous 2 years and symptoms more than weekly in the previous 3 months, regular preventer was associated with a reduction in serious flare-ups, school absence due to asthma, an increase in symptom-free days, and improved lung function, compared with placebo.13, 14

The Thoracic Society of Australia and New Zealand’s current position statement on the use of inhaled corticosteroids in children6 recommends regular treatment with inhaled corticosteroid:

  • as a first-choice preventer for children with asthma symptoms at least daily or night-time symptoms at least twice per week between flare-ups
  • as an alternative to cromones (nedocromil or sodium cromoglycate) or montelukast in children with any daytime or night-time symptoms between flare-ups, or those with flare-ups every 6 weeks or more.

Doses

In the majority of children, asthma control can be achieved with any of the following initial doses:6

  • budesonide up to 400 microg/day
  • beclometasone (Qvar) up to 200 microg/day
  • ciclesonide up to 160 microg/day
  • fluticasone propionate up to 200 microg/day.

If these doses do not achieve control of symptoms, possible explanations include alternative diagnoses, adherence, incorrect inhaler technique, psychosocial factors and exposure to tobacco smoke or other triggers such as allergens.6

Dose–response studies of inhaled corticosteroids show that the maximal efficacy is generally achieved at a dose equivalent to approximately 200 microg/day fluticasone propionate,6 while the risk of adrenal suppression increases exponentially at doses above 500 microg/day.6 Therefore (based on theoretical equivalents between different agents), upper limits of daily doses for children are:

  • budesonide 800 microg/day
  • beclometasone dipropionate [Qvar] 400 microg/day
  • ciclesonide 320 microg/day
  • fluticasone propionate 500 microg/day.

Higher doses are unlikely to be more effective, and are likely to cause systemic effects.6

Most studies of inhaled corticosteroids in children have used twice-daily dosing.6 Fluticasone propionate is only approved for twice-daily dosing, but the other inhaled corticosteroids are approved for once daily dosing. Ciclesonide is effective when given once daily.6

Note: Do not use beclometasone dose recommendations from outdated or overseas guidelines based on older formulations containing CFC propellant – doses are different.

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (microg)

Low

High

Beclometasone dipropionate

100–200

>200 (maximum 400)

Budesonide

200–400

>400 (maximum 800)

Ciclesonide

80–160

>160 (maximum 320)

Fluticasone propionate

100–200

>200 (maximum 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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Montelukast for children: efficacy
  • Montelukast use has been associated with behavioural and/or neuropsychiatric adverse effects, including suicidality.

Overview

Montelukast is a leukotriene receptor antagonist preventer. It is registered by the TGA for the treatment of asthma in children aged 2 years and older, and for the symptomatic treatment of allergic rhinitis.15

Montelukast can be used as an alternative to inhaled corticosteroids or as an add-on treatment in a child already taking regular inhaled corticosteroids.

However, it is not effective for all children. Overall, only approximately 20–30% of children will respond to montelukast treatment. The effect is thought to depend mainly on the child’s genotype.16, 17, 18 Clinically, it is not possible to predict accurately which children will benefit most from montelukast treatment.

Montelukast as first-line preventer in children aged 2–5 years

Viral-induced wheezing

Overall, regular maintenance montelukast treatment does not reduce the risk of wheezing episodes requiring oral corticosteroid treatment among preschool children who only have wheezing episodes when they have viral upper respiratory tract infections.19

However, montelukast may be effective for some children. Some randomised controlled trials have reported a reduction the risk of flare-ups in preschool children with intermittent asthma/wheeze,20, 21 while others have not.22

Persistent asthma or wheezing

A systematic review comparing montelukast with inhaled corticosteroids in preschoolers with asthma or recurrent wheezing requiring daily preventer treatment23 reported that inhaled corticosteroids appeared to achieve better symptom control and reduce flare-ups (including severe flare-ups requiring treatment with systemic corticosteroids). However, results were inconsistent and meta-analysis was not possible due to heterogeneity of outcomes measured in available clinical trials.23

Some preschool children with persistent asthma/wheeze respond to montelukast. A crossover study in preschool children with persistent asthma/wheeze reported that some children showed their best response to montelukast, while most responded better to regular inhaled corticosteroids.24 Predictors of a better response to inhaled corticosteroids than montelukast were aeroallergen hypersensitivity and blood eosinophilia (eosinophil counts ≥ 300/μL).24 However, routine blood eosinophil count is not feasible or recommended for this purpose.

Montelukast as first-line preventer children aged 6 years and over

In school-aged children with persistent asthma, inhaled corticosteroids are more effective overall than montelukast in improving lung function and controlling asthma symptoms.25, 27

However, symptoms will respond to a treatment trial of montelukast in approximately one-quarter to one-third of children,25, 28,29 and some may benefit more than from an inhaled corticosteroid.25 More severe asthma and markers of allergic inflammation may predict a better response to inhaled corticosteroids.25

Montelukast as add-on treatment

A systematic review of studies in children over 6 years and adolescents with mild-to-moderate persistent asthma found that the addition of montelukast to inhaled corticosteroids did reduce flare-ups requiring oral corticosteroids or hospital admissions for asthma, compared with the same or an increased dose.27

In a study comparing step-up treatments in children with asthma symptoms uncontrolled by low-dose inhaled corticosteroids, the addition of a long-acting beta2 agonist was effective in more children than either montelukast or increasing the dose of inhaled corticosteroid for controlling asthma symptoms and preventing flare-ups requiring systemic corticosteroids.30 However, some studies in school-aged children with persistent asthma already taking regular inhaled corticosteroids have reported that add-on montelukast reduced the risk of flare-ups30, 31 and exercise-induced asthma symptoms.31 Not all children will respond.

In a small study in children with persistent asthma already taking regular inhaled corticosteroids who were homozygous for the Arg16 genotype, montelukast was more effective as an add-on therapy than long-acting beta2 agonist in reducing symptoms, reliever use and days absent from school due to asthma, depending on the child’s beta receptor genotype.18 However, children were given inhaled corticosteroid and long-acting beta2 agonists in separate inhalers, which is which is known to be associated with increased risks.

However, genotyping it is not currently feasible in clinical practice. In practice, a treatment trial of 4–6 weeks can determine which preventer is suitable for controlling a child’s asthma symptoms,25 but longer treatment may be required to evaluate effect on flare-ups, because flare-ups may be independent of symptom control.

Exercise-induced symptoms

In school-aged children who experience exercise-induced symptoms despite taking regular inhaled corticosteroids, the addition of montelukast is effective in controlling symptoms, but not all children experience a response.32

See: Investigation and management of exercise-induced bronchoconstriction

Short-term use in the management of flare-ups

Some, but not all studies suggest that a short course of montelukast, introduced at the first signs of an upper respiratory tract infection, may be effective in controlling flare-ups. An Australian study reported that this strategy could achieve a small reduction in symptoms, school absence and medical consultations in preschool and school-aged children with episodic wheeze.33

However, the evidence is inconsistent, with some studies showing no benefit.22,34, 35, 36, 37 The findings of one study suggested that whether or not intermittent montelukast is effective in wheezing children aged 5 years and under depends on genotype.17

Montelukast is not TGA-approved or PBS-subsidised for intermittent use.

Note: PBS status as at March 2019: Montelukast is not subsidised by the PBS for adolescents 15 years and over.

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Administration of inhaled medicines in children: 6 years and over

Parents, carers and children need training to use inhaler devices correctly, including inhaler technique, and care and cleaning of inhalers and spacers.

School-aged children (depending on the child’s age, ability, and with individualised training) can learn to use a range of inhaler types, including manually actuated pressurised metered-dose inhalers with spacers, breath-actuated pressurised metered-dose inhalers (e.g. Autohaler), and dry-powder inhalers (e.g. Accuhaler, Turbuhaler).38, 39, 40, 41, 42

Table. Types of inhaler devices for delivering asthma and COPD medicines Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/75

A pressurised metered-dose inhaler and spacer is an appropriate first choice for most children.40

School-aged children are unlikely to use their inhaler device correctly without careful training and repeated checking.43

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Correct use of inhaler devices

Checking and correcting inhaler technique is essential to effective asthma management.

Most patients with asthma or COPD do not use their inhalers properly,1, 4-7 and most have not had their technique checked or corrected by a health professional.

Incorrect inhaler technique when using maintenance treatments increases the risk of severe flare-ups and hospitalisation for people with asthma or COPD.1, 4, 5, 14, 22, 23

Poor asthma symptom control is often due to incorrect inhaler technique.24, 25

Incorrect inhaler technique when using inhaled corticosteroids increases the risk of local side effects like dysphonia and oral thrush.

The steps for using an inhaler device correctly differ between brands. Checklists of correct steps for each inhaler type and how-to videos are available from the National Asthma Council website.

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References

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