Asthma Management Handbook

Reviewing initial treatment in children aged 1–5 years

Recommendations

When prescribing any preventer medicine for a child, consider each adjustment to the regimen as a treatment trial: monitor response continually, review within 4–6 weeks (or earlier as needed in response to parents’ concerns), and adjust treatment according to response.

Table. Reviewing and adjusting preventer treatment for children aged 1–5 years Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/table/show/25

Figure. Stepped approach to adjusting asthma medication in children aged 1-5 years Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/18

How this recommendation was developed

Consensus

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

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If symptoms are not controlled during treatment with a preventer (despite good adherence and correct inhaler technique), consider whether they may be due to comorbidity or an 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).

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If treatment-related behavioural and/or neuropsychiatric symptoms are suspected in a child taking montelukast, discontinue treatment and advise parents/carers to monitor and treat asthma symptoms with reliever while off preventer treatment.

If unsure whether a change in behaviour could be due to medication or normal for age, consider stopping for a short time (e.g. 1 week or more) and re-starting to monitor effects.

How this recommendation was developed

Consensus

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

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If parents/carers report behavioural changes possibly related to treatment in a child taking regular inhaled corticosteroids, consider reducing the dose, changing to a different corticosteroid and monitoring effect, or trialling a different preventer.

How this recommendation was developed

Consensus

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

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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):

  • Gibson et al. 20101
  • van Asperen et al. 20102

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More information

Classification of recent asthma symptom control in children

Ongoing review of asthma involves both assessing recent asthma symptom control and assessing risks for poor asthma outcomes such as flare-ups and adverse effects of medicines.

Recent asthma symptom control is assessed according to the frequency of asthma symptoms over the previous 4 weeks.

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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Table. Risk factors for life-threatening asthma flare-ups in children

Asthma-related factors

Poor asthma control

Admission to hospital in preceding 12 months

History of intubation for acute asthma

Over-use of short-acting beta2 agonist reliever

Abnormal spirometry findings

Reversible expiratory airflow limitation on spirometry despite treatment

Poor adherence to preventer

Incorrect inhaler technique for preventer

Poor adherence to asthma action plan

Exposure to clinically relevant allergens

Exposure to tobacco smoke

Other clinical factors

Allergies to foods, insects, medicines

Obesity

Family-related factors

Frequent failure to attend consultations/lack of follow-up after an acute flare-up

Significant parental psychological or socioeconomic problems

Parent/carer unequipped to manage asthma emergency

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Montelukast for children: behavioural and/or neuropsychiatric adverse effects

Montelukast is generally very well tolerated. Behavioural and psychiatric adverse effects were rare in clinical trials.3, 4 However, post-marketing surveillance reports have identified behavioural and/or neuropsychiatric adverse effects associated with montelukast use in some children.5

Behavioural treatment-associated effects are difficult to assess in young children. No factors have been identified to predict which children are at risk.

Reported adverse events include nightmares, sleep disturbance, anxiety, irritability, aggression and depression.5, 6, 7, 8

Suicidal ideation has been reported in adolescents and adults taking montelukast.8 A 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.9

Reported adverse effects are usually mild.7 The majority occur within 7–14 days of starting montelukast,5, 7 but some may appear after several months.8

Behavioural and/or neuropsychiatric adverse effects typically disappear within 4 days of stopping montelukast treatment.7 There is no evidence of long term effects.

The TGA recommends that clinicians treating children with montelukast should educate caregivers about these potential adverse effects and should consider providing them with the CMI. Advise them to seek medical advice if they have any concerns.

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Inhaled corticosteroids for children: adverse effects

Local adverse effects

Hoarseness and pharyngeal candidiasis are not commonly reported among preschool children or school-aged children talking inhaled corticosteroids. 10, 2, 11

Topical effects can be reduced by use of spacer devices (which reduce oropharyngeal deposition), and by mouth-rinsing and spitting after use.2 Immediate quick mouth-rinsing removes more residual medicine in the mouth than delayed rinsing.12

There is limited evidence that inhaled asthma medication can affect dental health.2, 13 Mouth rinsing might reduce this risk.

Systemic adverse effects

Systemic effects of inhaled corticosteroids in children depend on the dose, but clinically significant adverse effects are uncommon.2

The use of spacers and mouth rinsing will not reduce systemic effects, but the use of a spacer may increase efficacy so that a lower dose is required.

Growth

Short-term suppression of linear growth has been demonstrated in children taking inhaled corticosteroids.14,15 The effect seems to be maximal during the first year of therapy and only one study has reported an effect in subsequent years of treatment.15 A Cochrane systematic review concluded that regular use of inhaled corticosteroid at low or medium daily doses is associated with a mean reduction of 0.48 cm per year in linear growth velocity and 0.61 cm less gain in height during 1 year of treatment in children with mild to moderate persistent asthma.15

One study of patients who participated in a clinical trial of inhaled corticosteroids as children, reported a reduction in adult height of approximately 1 cm,14, 16, 17, 18 whereas several studies have reported that children taking inhaled corticosteroids attained normal adult height.19, 20, 21

The effect is dose-dependent17,18 and may be more likely in children who begin inhaled corticosteroid treatment before age 10.16

Other factors affect growth in children with asthma. Uncontrolled asthma itself reduces growth and final adult height.22 One study found that inhaled corticosteroid equivalent to budesonide 400 microg/day affected growth less than low socioeconomic status.21

Bone density

Inhaled corticosteroids have not been associated with effects on bone density or fractures in children. 2 However, data from a recent study in Australia suggested asthma itself is associated with increased incidence of fractures in children, independent of medication.23

Given that the total dose of corticosteroids (both inhaled corticosteroids and oral corticosteroids) influences bone health, the aim of asthma management is to maintain symptom control using the lowest inhaled corticosteroid dose required, and to avoid repeated courses of oral corticosteroids.

Adrenal suppression

Biochemical testing in a research setting suggests that hypothalamic–pituitary–adrenal axis suppression may occur in up to two-thirds of children treated with inhaled corticosteroids, and may occur at even low doses.24 The risk is higher among children receiving concomitant intranasal steroids and those with lower body mass index,24 and is influenced by genetics.25

Clinical adrenal insufficiency in children taking inhaled corticosteroids is rare but has been reported, 26, 27, 28 including cases in Australia.28 Most cases have involved children given more than 500 microg per day fluticasone propionate.26

Adrenal suppression is associated with hypoglycaemia, hypotension, weakness, failure to grow, and is potentially fatal. Hypothalamic–pituitary–adrenal axis suppression may not be detected until adrenal crisis is precipitated by physical stress.29

Written information (e.g. a steroid alert card) can be prepared for children receiving long-term high-dose inhaled corticosteroids. Parents/carers can be instructed to present the card if the child ever needs to go to the emergency department (for any reason) or be admitted to hospital. A steroid alert card should state that child has asthma and the inhaled corticosteroid dose. A medical alert bracelet could also be considered.

There are no nationally accepted protocols for routine assessment of adrenal function in primary care because it has not yet been possible to identify precisely which children should be tested, to interpret test results reliably, to identify the appropriate interval for retesting, and because a clinical benefit has not been clearly demonstrated.

Regular monitoring of height might help detect adrenal suppression, based on the findings of a study in which a reduction in linear growth velocity occurred before adrenal suppression.30

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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Administration of inhaled medicines in children: 1-5 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. 

Types of inhalers suitable for preschool children

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 actuating the device.10 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.10

Drug delivery is very variable in young children with any type of inhaler, including pressurised metered dose inhalers and spacers.20 Filter studies have shown high day-to-day variability in delivered doses in preschool children.10 This variation might explain fluctuations in effectiveness, even if the child’s parents have been trained to use the device correctly.

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

Pressurised metered-dose inhalers plus spacers for relievers

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.10 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.31

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, actuate one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).32 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.33

Face masks for infants

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.31 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

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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Step-up options in children with asthma that is not controlled by low-dose inhaled corticosteroids

In children whose asthma is inadequately controlled by low-dose inhaled corticosteroids alone (and adherence is good, inhaler technique is correct and diagnosis has been confirmed), treatment options include:

  • increasing the inhaled corticosteroid dose
  • adding montelukast
  • switching to inhaled corticosteroid/long-acting beta2 agonist combination.

Table. Step-up options for children when good asthma control is not achieved with low-dose ICS

Option

TGA-registered indications for add-on therapy

PBS considerations

High-dose ICS

N/A

Subsidised

ICS plus montelukast

2 years and over

2–5 years: not subsidised*

6–14 years: not subsidised unless for exercise-induced bronchoconstriction despite ICS treatment

15 years and over: not subsidised

ICS/long-acting beta2 agonist combination

4 years and over for fluticasone propionate/ salmeterol xinafoate

12 years and over for budesonide/formoterol fumarate dihydrate

Subsidised

  • Advise parents about potential adverse psychiatric effects of montelukast

* Montelukast is not subsidised for use in combination with other preventers or for children who require inhaled corticosteroids.

 Montelukast is subsidised for prevention of exercise-induced asthma if asthma is otherwise well controlled while taking optimal-dose inhaled corticosteroids – it is not otherwise subsidised in combination with inhaled corticosteroids (or inhaled corticosteroid/long-acting beta2 agonist combinations). 

‡ Montelukast is not subsidised for people aged over 15 years.

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In the majority of children with persistent asthma that requires preventive treatment, control can be achieved with one of these options.2

Few studies have been conducted in preschool-aged children. The preferred step-up option for children aged 6–12 years is controversial and guidelines differ in their recommendations.34

Increasing inhaled corticosteroid dose versus adding a long-acting beta2 agonist

In school-aged children with persistent asthma taking regular inhaled corticosteroid, the addition of a long-acting beta2 agonist does not reduce the rate of asthma flare-ups requiring systemic steroids compared with the same or higher doses of inhaled corticosteroid.35, 36 However, the long-acting beta2 agonist–inhaled corticosteroid was superior for improving lung function.35  Growth is reduced in children treated with higher-dose inhaled corticosteroid, compared with those taking same dose plus a long-acting beta2 agonist.35 

Adolescents may benefit more from combination inhaled corticosteroid/long-acting beta2 agonist treatment than children under 12 years. In adolescents with persistent asthma that is not controlled by a low dose of inhaled corticosteroids, the combination of a long-acting beta2 agonist and an inhaled corticosteroid is modestly more effective in reducing the risk of flare-ups requiring oral corticosteroids than a higher dose of inhaled corticosteroids.37

Adding montelukast versus adding a long-acting beta-2 agonist or increasing inhaled corticosteroid dose

Children aged 1–5 years

In one study in children aged 5 years or less with persistent asthma/wheeze requiring preventer treatment, raised blood eosinophil levels and atopy predicted better short-term response to high-dose inhaled corticosteroid than to montelukast.38 However, routine eosinophil counts are currently not recommended to guide treatment in children.

In children aged 1–5 years with asthma/wheeze that is not adequately controlled by low-dose inhaled corticosteroid alone, adding montelukast is preferable to increasing the dose of inhaled corticosteroids when the safety profiles of these options are compared.39 Long-acting beta2 agonists are not recommended for this age group.

  • Montelukast use has been associated with behavioural and/or neuropsychiatric adverse effects.

Note: Montelukast is TGA-approved for children aged 2 years and over.

Children aged 6 years and over

Among children 6 years and over with asthma that is not controlled by low-dose inhaled corticosteroids, the optimal regimen varies between individuals.40 In one study of children selected for high adherence with maintenance treatment, short-term responses varied between individuals: in some children the best response was achieved by adding a long-acting beta2 agonist, in others by adding montelukast, and in others by increasing the dose of inhaled corticosteroid.40

Note: The use of inhaled corticosteroids and long-acting beta2 agonists in separate inhalers is not recommended for either children or adults because of the potential for increased risk due to selective non-adherence to the inhaled corticosteroid.41

Overall, the addition of montelukast to an inhaled corticosteroid does not reduce the need for rescue oral corticosteroids or hospital admission, compared with the same or an increased dose of inhaled corticosteroids, in children aged 6 years and over or adolescents with mild-to-moderate asthma.42

For children aged 6–14 years with persistent asthma and exercise-induced bronchoconstriction, adding montelukast is more effective in protecting against exercise-induced bronchoconstriction than switching to a combination of inhaled corticosteroid and a long-acting beta2 agonist.43 The use of montelukast also avoids beta-receptor tolerance associated with long-acting beta2 agonists, so a short-acting beta2 agonist taken after exercise produces a greater bronchodilator response than it does in children taking regular long-acting beta2 agonist.43

A treatment trial of montelukast for 4–6 weeks is the best option when effects on exercise-induced symptoms and safety are also considered.39

  • Montelukast use has been associated with behavioural and/or neuropsychiatric adverse effects.

See: Investigation and management of exercise-induced bronchoconstriction

 

Genetic influence on effect of long-acting beta2 agonists

Clinical response to long-acting beta2 agonists partly depends on genetics. A beta2receptor genotype  (Arg16 polymorphism in the beta2 receptor gene) pre-disposes children with asthma to down-regulation of the beta2 receptor and increased susceptibility to flare-ups during regular treatment with regular long-acting beta2agonists.44 However, routine genetic testing to tailor asthma therapy is not yet available in clinical practice.

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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.45

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.46, 7, 47 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.38

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,48, 49 while others have not.8

Persistent asthma or wheezing

A systematic review comparing montelukast with inhaled corticosteroids in preschoolers with asthma or recurrent wheezing requiring daily preventer treatment50 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.50

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.51 Predictors of a better response to inhaled corticosteroids than montelukast were aeroallergen hypersensitivity and blood eosinophilia (eosinophil counts ≥ 300/μL).51 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.52, 54

However, symptoms will respond to a treatment trial of montelukast in approximately one-quarter to one-third of children,52, 55,56 and some may benefit more than from an inhaled corticosteroid.52 More severe asthma and markers of allergic inflammation may predict a better response to inhaled corticosteroids.52

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.54

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.36 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-ups36, 57 and exercise-induced asthma symptoms.57 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.47 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,52 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.58

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.59

However, the evidence is inconsistent, with some studies showing no benefit.8,3, 60, 5, 61 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.7

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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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 
  • the degree to which asthma symptoms affect daily activities such as interference with physical activity or missed school days)
  • the frequency of flare-ups
  • spirometry in children who are able to perform the test reliably.

Standardised questionnaires

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

Lung function tests

Frequent spirometry to guide asthma treatment in children has not been shown to achieve superior outcomes to symptom-based treatment.[REFERENCE1739] Current evidence does not support use of home spirometers to guide asthma treatment in children.67 However, low FEV1 predicts clinically significant flare-ups, so spirometry should be performed at asthma reviews for children who are old enough to do the test.
The quality and utility of spirometry depends on the skill, clinical expertise and experience of the person doing and interpreting spirometry.

The results of one study in children aged 6–16 years with moderate atopic asthma suggest that asthma treatment guided by airway hyperresponsiveness (measured by bronchial provocation testing) may have a benefit over symptom-guided treatment in improving lung, but this effect was lost after 3–7 years of usual care.68, 69 Repeated bronchial provocation testing is not feasible in clinical practice.

Measures of airway inflammation

Measures of airway inflammation (e.g. sputum eosinophil count, exhaled nitric oxide measurement) are not recommended in primary care to guide treatment decisions, but are increasingly used in specialist clinics.

Asthma treatment guided by sputum eosinophil count has been shown to reduce the frequency of flare-ups in adults with asthma, but there is insufficient evidence to ascertain its value for children.70

Exhaled nitric oxide measurement may be useful in guiding asthma management in some children. In children not taking inhaled corticosteroid, a high nitric oxide level probably predicts a good short-term response to inhaled corticosteroid treatment,71 but it does not distinguish between asthma and eosinophilic bronchitis and is often high in children with atopy. There is insufficient evidence to ascertain whether a low exhaled nitric oxide level predicts successful withdrawal from inhaled corticosteroids without asthma relapse,71 or safety of treating asthma without inhaled corticosteroids.

A Cochrane review72 found that exhaled nitric oxide-guided management was significantly better than other approaches to adjusting medicines for reducing the number of children with flare-ups and the number of children who needed oral corticosteroids, but did not reduce the frequency of flare-ups or the rate of flare-ups requiring hospitalisation, improve lung function or symptoms scores, or reduce inhaled corticosteroid doses. The authors concluded that it could not be recommended for all children but may be beneficial for a subset not yet defined.72

Towards personalised asthma care

Emerging understanding of asthma phenotypes and of genetic factors that predict therapeutic response to preventer options is leading to the possibility of personalised, genomics-based treatment for asthma in children.73 In the near future, individual tailored therapy is may replace the standardised step model based on population data.

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Common reasons for poor response to preventer treatment

Apparent lack of response to asthma treatment is commonly due to one or more of the following:74

  • poor adherence (which may be due to lack of perceived need for the medication, concern about potential or actual side-effects, cost of medicines, a busy lifestyle, misunderstanding of the purpose and effects of asthma medicines, or inability to follow the medical instructions)
  • poor inhaler technique
  • mishandling devices (e.g. failure to clean spacer, allowing mouthpiece of dry-powder inhalers to become blocked)
  • incorrect dose or frequency
  • empty inhaler
  • expired medicines
  • continued exposure to smoke or allergen triggers.

Failure to identify these causes before adjusting medicines could result in over-medication with preventers.

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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.1 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.1

  • There are significant concerns about use of cough medicines in children.

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References

  1. 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: https://www.mja.com.au/journal/2010/192/5/cicada-cough-children-and-adults-diagnosis-and-assessment-australian-cough
  2. 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: https://www.thoracic.org.au/journal-publishing/command/download_file/id/25/filename/The_role_of_corticosteroids_in_the_management_of_childhood_asthma_-_2010.pdf
  3. Watts, K, Chavasse, R J P G. Leukotriene receptor antagonists in addition to usual care for acute asthma in adults and children. Cochrane Database Syst Rev. 2012; Issue 5: . Available from: http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD006100.pub2/full
  4. 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
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