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).
According to these recommendations, the following steps are distinguished:
- 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).
- 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.
- 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.
- 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.
- 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.