Steps of Asthma Treatment in Children Under 5 Years Old

For the selection of basic treatment for either for asthmatic children or adults, step approach is used. The goal of basic treatment is to achieve control over asthma. The control of asthma means the absence of bronchial obstruction attacks. This article will describe step approaches for children under 5 years. Children from 6 years old receive treatment on the same principle as adults.

There are two international normative documents that reflect the approach of step therapy: PRACTALL (2012) and GINA (last edition of 2016).

The Step Therapy in Children under 5 with Asthma

According to these recommendations, the following steps are distinguished:

1 step:

  • this stage includes patients with rare (less than 3 per year) obstructions, which usually arise on the background of viral infections;
  • treatment includes therapy with short-acting bronchodilators when needed (salbutamol, Ventolin, Berodual).

2 step:

  • patients who have asthma and obstructions symptoms appear more than 3 times a year, or patients with wheezing attacks every 6-8 weeks;
  • the first-line choice drugs are inhaled steroids in low doses (for example, 250 μg of Pulmicort by means of a nebulizer 2 times/day);
  • the duration of therapy is not less than 3 months, after which its effectiveness is evaluated and a decision is made on further treatment;
  • an alternative preparation is Montelukast (Singulair and its analogs).

The instructions given in PRACTALL and GINA differ.

  • PRACTALL: Singulair can be used in case of virus-induced asthma and in refusal from steroid therapy.
  • GINA: studies show a weak effectiveness of Singulair in comparison with inhaled steroids.

In practice, we are faced with steroid phobia, so we are forced to follow the first recommendation, but in practice, the GINA approach is more effective.

3 step:

  • this stage includes patients who do not control asthma being on the 2nd stage;
  • treatment includes a doubled low dose of inhaled steroids or the start of using Singulair on the 2nd stage;
  • the appointment of combined drugs (iGCS + bronchodilators with a long-lasting effect) in older children. Seretide can be taken from 4 years old, Symbicort – 6 years old.


Tiotropium bromide (trade name Spiriva Respimat) is a long-acting bronchodilator drug from the m-cholinoblockers group.

It can be appointed as an additional maintenance therapy in patients of 6 years old suffering from bronchial asthma, with persisting the disease’ symptoms on the background of taking at least inhaled glucocorticosteroids;

Short-acting bronchodilators on demand are prescribed to reduce the symptoms of bronchial asthma, improve the quality of life and decrease the frequency of exacerbations.

4 step:

  • this group includes patients with severe asthma if the control is not achieved on 3rd steps;
  • increase the frequency of inhaled steroids;
  • short-acting bronchodilator drugs as required;
  • The transition from one step to another is called “step up”.

At each step up the doctor necessarily evaluates before changing one therapy to another:

  • whether the therapy is correctly conducted;
  • whether the diagnosis is correct;
  • what the risk factors are (smoking, environmental factors, contact with the allergen).

Considering that bronchial obstructive syndrome in children under 5 years of age may be non-atopic, that is, there is a chance of overgrowing. It is very important to regularly change the therapy and evaluate the dynamics and effectiveness of the treatment.

5 step:

  • this is a group including the patients with a severe bronchial asthma, which cannot be controlled by high doses of combined drugs (iGCS + LABA: Seretide, Symbicort, etc.) in combination with m-cholinoblockers (Spiriva Respimat).
  • at this stage, systemic GCS (tableted Prednisolon) can be added.
  • also, biological therapy can be considered: anti-IgE therapy.

The main representative is Omalizumab. It is used to treat persistent atopic bronchial asthma of moderate and severe course, the symptoms of which are not adequately controlled by the use of GCS in patients 6 years and older.

Fortunately, in children, 5 step is rarely observed. But among adults, the level is considerably higher.

Category: Asthma School

Posted by

31 responses to “Steps of Asthma Treatment in Children Under 5 Years Old”

  1. Ani_cross says:

    Tell me, please! The child from June to October received Pulmocort 2 times a day for 1 ml (250). Then, the doctor recommended a dose of 0.25 1 time in the evening taken for 4 months. At the same time, the child was often sick with ARVI (we always have obstructions) but there were no sings of this symptom. During the day, there is a slight cough. There is an allergy to dust by analysis (in fact, I do not notice). Is it correct that the doctor reduces the dosage to such a small one? Another pulmonologist told us that this is too small dose, and then it is necessary to withdraw the medication anyway.

    • Asthma.School says:

      Please, remind the age of the child.

      • Ani_cross says:

        4 years 4 months.

        • Asthma.School says:

          If at a dose of 1 ml there was no obstruction in the evening, it is permissible to remain at such a dose on an individual basis. In general, the minimum dose is 1 ml (250 μg) 2 times a day.

          • Ani_cross says:

            This dose doesn’t provoke an obstruction. We, therefore, withdraw the medication. My daughter did not get sick for a month and everything seems normal. But she began coughing during the day. To evening the coughing becomes stronger. Then, she drank warm milk and slept well. Does this mean we still need to do inhalations?

          • Ani_cross says:

            Then, the daughter fell ill. And at this moment, we visited another pulmonologist for the first time. The doctor decided that we were in an exacerbation. There is no obstruction. But she prescribed again inhalations to May. I addressed asthma school with doubts about the given appointments. We then decided to inhale Berodual and Pulmicort. And then, we plan to try Singulair. 10 days have passed. A cough persists in the morning and a little during the day (until the throat is clear). The peakflowmeter indicators are normal. Is it worth further doing inhalations?

            • Asthma.School says:

              here it is necessary to monitor the child. Perhaps you need Pulmicort or Singulair as monotherapy (if the child is older than 2 years).

  2. ann_sun says:

    Tell me please what dosage of Pulmicort should be if the dosage of Flixotide is 50 mg 2 doses 2 times a day because we are mistaken in inhaling the medication.

  3. ann_sun says:

    3 years

  4. helenfox says:

    If ARVI occurs on the background of basic therapy, we add Berodual as soon as the initial dry cough appears and it did not transform into the obstruction. Is it necessary to carry out another long course of therapy? How to understand it? Do new obstructions start and Berodual won’t help, right? My child is 3,5. Pulmicort was taken 8 months after being taken to the hospital. Obstruction occurred from the age of 1 year, then the diagnosis was established as BA, at that time we withdrew the basic therapy. Additionally, we have an expressed food allergy.

  5. 12Nathan says:

    My child is 5 years old. Once a month we have the obstruction, any virus causes the obstruction. Once, we were taken into the intensive care unit. There, we grappled with pulseoxymetry device, we bought it (there is a peakflowmeter, now we measure everything, thanks to your school). But our allergist did not prescribe long-term use of iGCS, only when the exacerbation, we take Berodual + Pulmicort, when we remove the swelling usually in one day, we inhale Pulmicort through the nebulizer within 5 days. Now we take Montelukast. I noticed if we took a generic, obstructions were observed, now we take Singulair for 3 months, there is no obstruction. We suffered from flu, but it did not transform into the obstruction. The allergologist has appointed Broncho-munal and Imudon but I do not give it. Help us please, as I understand, our doctors know less than we. Whether is it necessary to apply iGCS therapy or while to follow the further effect and result of Singulair?

  6. sunnygirl says:

    We were treated with Flixotide and Montelukast for 3 months. My son is 9 years old, there is still obstruction when ARVI. At least the first-day test, instead of 270 (100%), exhalation was 180, without ARVI every day exhalation is 270 and sometimes even higher, there are no obstructions. What further treatment will you recommend? I again started Flixotide for 3 months, may again need Montelukast?

    • Asthma.School says:

      It is necessary to increase the dose of basic therapy or change Flixotide to a combined drug (Seretide or Symbicort) but this should be done by the personal doctor.

      • sunnygirl says:

        Why is it impossible to repeat the same basic therapy? Is the effect obtained when there is a dosage increase? We will address to the doctor certainly, but I should understand everything. Thank you!

        • Asthma.School says:

          According to your words, the effect of the therapy was not observed. You write that there are obstructions caused by ARVI. Did these obstructions occur during treatment?

  7. sunnygirl says:

    No! During the treatment, there are no symptoms of even ARVI! I was happy during these 3 months. But I am disappointed they are over! It was until New Year, and even after the treatment, there was no ARVI for a month. And now it appears again.

  8. sunnygirl says:

    I apparently did not clearly explain, the treatment was Oct / Nov / Dec. Now in March, my son again became ill with ARVI, there was a non-severe one-day obstruction (Berodual + Pulmicort for 2 days).

  9. sunnygirl says:

    Resume all the therapy? With Montelukast? Or is it now possible to take Flixotide only? And for how long?

    • Asthma.School says:

      The detailed treatment plan with the choice of the drug must be decided when examined by a doctor. The minimum duration of treatment is 3 months. If, after the drug is discontinued, obstructions are resumed, it is necessary to decide on the longer application of basic therapy (6-12 months).

  10. 12Nathan says:

    Tell me please, we are taking Montelukast therapy for 7months already. Is it scary if I forgot to give Singulair? Naturally, it happens very rarely but still whether it brings damages or not.

Leave a Reply

Your email address will not be published. Required fields are marked *