Asthma Management Handbook

Reviewing initial treatment in children 0–5 years

Recommendations

When prescribing any preventer medicine for a child, consider each treatment adjustment as a treatment trial: monitor response continually, review within 4 weeks, and adjust treatment according to response.

Figure. Stepped approach to adjusting asthma medication in children Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/figure/show/18

Table. Reviewing and adjusting preventer treatment for children aged 0–5 years Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/25

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1
  • National Asthma Council Australia, 2010 2
  • Brand et al. 2008 3

If symptoms have been well controlled for at least 3 months in a child taking regular inhaled corticosteroid treatment, reduce the dose to find the minimal dose needed to control symptoms.

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (mcg)

Low

High

Beclometasone dipropionate

100–200

>200 (up to 400)

Budesonide

200–400

>400 (up to 800)

Ciclesonide

80–160

>160 (up to 320)

Fluticasone propionate

100–200

>200 (up to 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

Asset ID: 21

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How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1
  • Brand et al. 2008 3

If symptoms are well controlled for at least 3 months on the lowest available inhaled corticosteroid dose, consider the following options:

  • Stop preventer treatment completely, while monitoring the response, to judge whether symptoms have resolved.
  • Replace inhaled corticosteroid with a trial of montelukast or a cromone. If well controlled for a further 3 months, stop preventer treatment and monitor the response.
  • Advise parents about potential adverse psychiatric effects of montelukast

Figure. Stepped approach to adjusting asthma medication in children Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/figure/show/18

Table. Reviewing and adjusting preventer treatment for children aged 0–5 years Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/25

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • van Asperen et al. 20101
  • Brand et al. 20083

If symptoms are not controlled, consider whether they may be due to a comorbidity or alternative diagnosis such as rhinosinusitis or suppurative lung disease.

How this recommendation was developed

Consensus

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

If cough is the predominant symptom, carefully reassess the diagnosis before changing treatment. Do not use inhaled corticosteroids specifically for cough. Refer to national guidelines for diagnosis and management of cough. 

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1
  • Gibson et al. 2010 4

More information

Approaches to assessment and monitoring of asthma control in children

Assessment of asthma control in children is based mainly on recent asthma symptom control (assessed by the frequency and severity of symptoms between flare-ups and the degree to which asthma symptoms affect daily activities such as interference with physical activity or missed school days), the frequency of flare-ups, and spirometry in children who are able to perform the test reliably.

Parents commonly underestimate the severity of their child's asthma and overestimate asthma control.5

Standardised questionnaires

Questionnaire-based instruments have been validated for assessing asthma control in children:

Measures of airway inflammation

Measures of airway inflammation (e.g. sputum test, exhaled nitric oxide) are not used in clinical practice to guide treatment decisions. Tailoring the dose of inhaled corticosteroids based on exhaled nitric oxide appears to achieve only a small benefit in children, and may lead to higher doses.11 

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Administration of inhaled medicines in children: 0–5 years

To use inhaler devices correctly, parents and children need training in inhaler technique and in the care and cleaning of inhalers and spacers.

Children need careful supervision when taking their inhaled medicines (e.g. at preschool), especially when using a reliever for acute asthma symptoms. 

During acute wheezing episodes, delivery of short-acting beta2 agonist to airways is more effective with a pressurised metered-dose inhaler plus spacer than with a nebuliser.3 In older children, salbutamol has also been associated with a greater increase in heart rate when delivered by nebuliser than when delivered by pressurised metered-dose inhaler plus spacer.12

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.3

Preschool children cannot use pressurised metered-dose inhalers properly unless a spacer is attached (with mask when necessary), because it is difficult for them to coordinate inspiratory effort with firing the device.3 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

Even when using pressurised metered dose inhalers and spacers, drug delivery is very variable in young children.13 The inhaler design may improve spacer technique,13 but will not necessarily improve clinical outcomes. The amount of medicine delivered by inhaler devices to the lower airways varies from day to day in preschool children.3 This variation might explain fluctuations in effectiveness, even if the child’s parents have been trained to use the device correctly.

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, fire one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).14 Fewer breaths may suffice; in children with asthma aged 2–7 years (not tested during an acute asthma episode), the number of tidal breaths needed to inhale salbutamol adequately from a spacer has been estimated at 2 breaths for small-volume spacers, 2 breaths for a spacer made from a 500-mL modified soft drink bottle, and 3 breaths for a large (Volumatic) spacer.15

When using a spacer with face mask (e.g. for an infant too young or uncooperative to be able to use a mouthpiece), effective delivery of medicine to the airways depends on a tight seal around the face. When masks are used for inhaled corticosteroids, there is a risk of exposure to eyes and skin if the seal over the mouth and nose is not adequate. Parents should be advised to wash the child's face after administering inhaled corticosteroids by mask.

Babies are unlikely to inhale enough medicine while crying.12 The use of a spacer and face mask for a crying infant may require patience and skill: the child can be comforted (e.g. held by a parent, in own pram, or sitting on the floor) while the mask is kept on, and the actuation carefully timed just before the next intake of breath. Most infants will tolerate the spacer and mask eventually. The child may be more likely to accept the spacer and mask if allowed to handle them first (and at other times), if the devices are personalised (e.g. with stickers), or if the mask has a scent associated with the mother (e.g. lip gloss). The use of a spacer with a coloured valve allows parents to see the valve move as the child breathes in and out.

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Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.1617

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,18, 19, 20, 21, 22 even among regular users.23 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.24

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.18, 25, 23, 26, 27 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.23

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.28, 29

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:24

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:24

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.24 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.30, 18, 31, 32 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.31 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).16, 29

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.28, 18, 19 

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Managing cough in children

When cough is the predominant symptom in a young child, careful assessment is needed to avoid making an incorrect diagnosis of asthma, or instigating inappropriate treatment.4 Cough alone (recurrent non-specific cough) is most likely due to recurrent viral bronchitis, which is unresponsive to both bronchodilators and preventive therapy including inhaled corticosteroids. Recurrent non-specific cough usually resolves by age 6 or 7 years and leaves no residual pulmonary pathology.

If cough is a problem for a child with known asthma, it should be managed according to national Cough in Children and Adults: Diagnosis and Assessment (CICADA) guidelines.4

  • There are significant concerns about use of cough medicines in children.
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Montelukast for children: warning parents about potential psychiatric adverse effects

Montelukast is generally very well tolerated.1 However, post-marketing surveillance reports suggested a slight increase in the rate of psychiatric disorders that was possibly associated with use of leukotriene receptor antagonists in children;33 this association may have been confounded by asthma severity and concomitant medication.1 Montelukast use has also been associated with suicidal ideation, but a recent nested case-control study concluded that children with asthma aged 5–18 years taking leukotriene receptor antagonists were not at increased risk of suicide attempts.34 Behavioural and psychiatric adverse effects were rare in clinical trials.35,36

A recent analysis of databases of adults and children taking montelukast suggests it is associated with nightmares, depression, and aggression.37 Allergic granulomatous angiitis has also been reported, but a causal relationship has not been established.37

The Thoracic Society of Australia and New Zealand advises that it is prudent to mention to parents the potential association of montelukast with behaviour-related adverse events when commencing treatment, and to cease therapy if such adverse events are suspected.1

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References

  1. 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
  2. National Asthma Council Australia. Leukotriene receptor antagonists in the management of childhood asthma. National Asthma Council Australia, Melbourne, 2010. Available from: http://www.nationalasthma.org.au/publication/ltras-their-role-in-childhood-asthma
  3. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from: http://erj.ersjournals.com/content/32/4/1096.full
  4. 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: 265-271. Available from: http://www.lungfoundation.com.au/professional-resources/guidelines/cough-guidelines
  5. Carroll WD, Wildhaber J, Brand PL. Parent misperception of control in childhood/adolescent asthma: The room to breathe survey. Eur Respir J. 2011; 39: 90-96. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21700607
  6. Juniper EF, Gruffydd-Jones K, Ward S, Svensson K. Asthma Control Questionnaire in children: validation, measurement properties, interpretation. Eur Respir J. 2010; 36: 1410-6. Available from: http://erj.ersjournals.com/content/36/6/1410.long
  7. 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: 833-9. Available from: http://www.jacionline.org/article/S0091-6749(09)00212-7/fulltext
  8. 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: 983-8. Available from: http://www.jacionline.org/article/S0091-6749(11)01287-5/fulltext
  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: 817-25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17353040
  10. Liu AH, Zeiger RS, Sorkness CA, et al. The Childhood Asthma Control Test: retrospective determination and clinical validation of a cut point to identify children with very poorly controlled asthma. J Allergy Clin Immunol. 2010; 126: 267-73, 273.e1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20624640
  11. Petsky HL, Cates CJ, Li A, et al. Tailored interventions based on exhaled nitric oxide versus clinical symptoms for asthma in children and adults. Cochrane Database Syst Rev. 2009; Issue 4: CD006340. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006340.pub3/full
  12. Schuh, S., Johnson, D. W., Stephens, D., et al. Comparison of albuterol delivered by a metered dose inhaler with spacer versus a nebulizer in children with mild acute asthma. The Journal of pediatrics. 1999; 135: 22-7. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10393599
  13. Schultz A, Sly PD, Zhang G, et al. Incentive device improves spacer technique but not clinical outcome in preschool children with asthma. J Paediatr Child Health. 2012; 48: 52-6. Available from: http://onlinelibrary.wiley.com/doi/10.1111/j.1440-1754.2011.02190.x/full
  14. National Asthma Council Australia. Kids' First Aid for Asthma. National Asthma Council Australia, Melbourne, 2011. Available from: http://www.nationalasthma.org.au/first-aid
  15. Schultz A, Le Souëf TJ, Venter A, et al. Aerosol inhalation from spacers and valved holding chambers requires few tidal breaths for children. Pediatrics. 2010; 126: e1493-8. Available from: http://pediatrics.aappublications.org/content/126/6/e1493.long
  16. Basheti IA, Armour CL, Bosnic-Anticevich SZ, Reddel HK. Evaluation of a novel educational strategy, including inhaler-based reminder labels, to improve asthma inhaler technique. Patient Educ Couns. 2008; 72: 26-33. Available from: http://www.ncbi.nlm.nih.gov/pubmed/18314294
  17. Bosnic-Anticevich, S. Z., Sinha, H., So, S., Reddel, H. K.. Metered-dose inhaler technique: the effect of two educational interventions delivered in community pharmacy over time. The Journal of asthma : official journal of the Association for the Care of Asthma. 2010; 47: 251-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  18. Price, D., Bosnic-Anticevich, S., Briggs, A., et al. Inhaler competence in asthma: common errors, barriers to use and recommended solutions. Respiratory medicine. 2013; 107: 37-46. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23098685
  19. Capanoglu, M., Dibek Misirlioglu, E., Toyran, M., et al. Evaluation of inhaler technique, adherence to therapy and their effect on disease control among children with asthma using metered dose or dry powder inhalers. The Journal of asthma : official journal of the Association for the Care of Asthma. 2015; 52: 838-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20394511
  20. Lavorini, F., Magnan, A., Dubus, J. C., et al. Effect of incorrect use of dry powder inhalers on management of patients with asthma and COPD. Respiratory medicine. 2008; 102: 593-604. Available from: https://www.ncbi.nlm.nih.gov/pubmed/18083019
  21. Federman, A. D., Wolf, M. S., Sofianou, A., et al. Self-management behaviors in older adults with asthma: associations with health literacy. Journal of the American Geriatrics Society. 2014; 62: 872-9. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24779482
  22. Crane, M. A., Jenkins, C. R., Goeman, D. P., Douglass, J. A.. Inhaler device technique can be improved in older adults through tailored education: findings from a randomised controlled trial. NPJ primary care respiratory medicine. 2014; 24: 14034. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25188403
  23. Melani AS, Bonavia M, Cilenti V, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21367593
  24. National Asthma Council Australia. Inhaler technique for people with asthma or COPD. National Asthma Council Australia, Melbourne, 2016. Available from: https://www.nationalasthma.org.au/living-with-asthma/resources/health-professionals/information-paper/hp-inhaler-technique-for-people-with-asthma-or-copd
  25. Bjermer, L.. The importance of continuity in inhaler device choice for asthma and chronic obstructive pulmonary disease. Respiration; international review of thoracic diseases. 2014; 88: 346-52. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25195762
  26. Haughney, J., Price, D., Barnes, N. C., et al. Choosing inhaler devices for people with asthma: current knowledge and outstanding research needs. Respiratory medicine. 2010; 104: 1237-45. Available from: https://www.ncbi.nlm.nih.gov/pubmed/20472415
  27. Giraud, V., Roche, N.. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. The European respiratory journal. 2002; 19: 246-51. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11866004
  28. Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Improved asthma outcomes with a simple inhaler technique intervention by community pharmacists. J Allergy Clin Immunol. 2007; 119: 1537-8. Available from: http://www.jacionline.org/article/S0091-6749(07)00439-3/fulltext
  29. Giraud, V., Allaert, F. A., Roche, N.. Inhaler technique and asthma: feasability and acceptability of training by pharmacists. Respiratory medicine. 2011; 105: 1815-22. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21802271
  30. Basheti, I. A., Reddel, H. K., Armour, C. L., Bosnic-Anticevich, S. Z.. Counseling about turbuhaler technique: needs assessment and effective strategies for community pharmacists. Respiratory care. 2005; 50: 617-23. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15871755
  31. Lavorini, F.. Inhaled drug delivery in the hands of the patient. Journal of aerosol medicine and pulmonary drug delivery. 2014; 27: 414-8. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25238005
  32. Newman, S.. Improving inhaler technique, adherence to therapy and the precision of dosing: major challenges for pulmonary drug delivery. Expert opinion on drug delivery. 2014; 11: 365-78. Available from: https://www.ncbi.nlm.nih.gov/pubmed/24386924
  33. Wallerstedt SM, Brunlöf G, Sundström A, Eriksson AL. Montelukast and psychiatric disorders in children. Pharmacoepidemiol Drug Saf. 2009; 18: 858-864. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19551697
  34. Schumock GT, Stayner LT, Valuck RJ, et al. Risk of suicide attempt in asthmatic children and young adults prescribed leukotriene-modifying agents: a nested case-control study. J Allergy Clin Immunol. 2012; 130: 368-75. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22698520
  35. Philip G, Hustad C, Noonan G, et al. Reports of suicidality in clinical trials of montelukast. J Allergy Clin Immunol. 2009; 124: 691-6.e6. Available from: http://www.jacionline.org/article/S0091-6749(09)01247-0/fulltext
  36. Philip G, Hustad CM, Malice MP, et al. Analysis of behavior-related adverse experiences in clinical trials of montelukast. J Allergy Clin Immunol. 2009; 124: 699-706.e8. Available from: http://www.jacionline.org/article/S0091-6749(09)01248-2/fulltext
  37. Haarman, MG, van Hunsel, F, de Vries, TW. Adverse drug reactions of montelukast in children and adults. Pharmacol Res Perspect. 2017; 5: e00341. Available from: http://onlinelibrary.wiley.com/doi/10.1002/prp2.341/full