Pocket Guide for

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Asthma Management and

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Prevention in Children
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5 Years and Younger

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A Pocket Guide for Physicians and Nurses

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2009
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BASED ON THE GLOBAL STRATEGY FOR

ASTHMA MANAGEMENT AND PREVENTION IN CHILDREN 5 YEARS AND YOUNGER

Available from www.ginasthma.org

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Disclaimer: Although the recommendations of this document are based on the best published
evidence, it is the responsibility of practicing physicians to consider the cost and benefit of all
treatments prescribed in young children, with due reference to recommendations and licensed
formulations, dosing, and indications for use in their country.
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GLOBAL INITIATIVE
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FOR ASTHMA
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GLOBAL INITIATIVE FOR ASTHMA

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Executive Committee (2009) Pediatric Writing Group

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Eric D. Bateman, M.D., South Africa, Chair Allan Becker, MD, Canada
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Louis-Philippe Boulet, MD, Canada Robert F. Lemanske, Jr, MD, USA

Alvaro Cruz, MD, Brazil Soren Erik Pedersen, MD, Denmark
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Mark FitzGerald, M.D., Canada Peter D. Sly MD, Australia

Tari Haahtela, M.D., Finland Manuel Soto-Quiroz, MD, Costa Rica
OR

Mark Levy, MD, UK Gary W. Wong, MD, Hong Kong ROC

Paul O'Byrne, M.D., Canada Heather J. Zar, MD, South Africa
Ken Ohta, M.D., Japan
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Pierluigi Paggario, M.D., Italy

Soren Pedersen, M.D., Denmark
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Manuel Soto-Quiroz, M.D., Costa Rica

Gary Wong, M.D., Hong Kong ROC
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2009 Medical Communications Resources, Inc.

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TABLE OF CONTENTS
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PREFACE .......................................................................................2
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WHAT IS KNOWN ABOUT ASTHMA?...........................................3

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DIAGNOSING ASTHMA ..............................................................4

Table 1. Is it Asthma? ..........................................................4
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CLASSIFICATION OF ASTHMA BY LEVEL OF CONTROL ...............5

Table 2. Levels of Asthma Control in Children
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5 Years and Younger ...............................................5

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MANAGEMENT AND PHARMACOLOGIC TREATMENT .................6

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Develop a Partnership Family/Caregivers and Health Care

, DO

Providers Identify and Reduce Exposure to Risk Factors ................6

Table 3. Strategies for Avoiding Common Allergens and

NO

Pollutants................................................................7
TA

Assess, Treat, and Monitor Asthma ...............................................8

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Table 4. Asthma Management Approach Based on Control

ER

for Children 5 Years and Younger .............................9

Table 5.
Low Daily Doses of Inhaled Glucocorticosteroids for
OR

Children 5 Years and Younger ..............................10

Manage Acute Exacerbations ......................................................12
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Table 6. Initial Assessment of Acute Asthma in Children

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5 Years and Younger...............................................13

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Table 7. Indications for Immediate Referral to Hospital

(Health Center) .......................................................14
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Table 8. Initial Management of Acute Asthma in Children

5 Years and Younger...............................................15
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1
 PREFACE
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Asthma is a major cause of chronic morbidity and mortality throughout the

over the past 20 years, especially in children. The Global Initiative for
world and there is evidence that its prevalence has increased considerably
RI

Asthma was created to increase awareness of asthma among health pro-

GH

fessionals, public health authorities, and the general public, and to improve
TE

prevention and management through a concerted worldwide effort. The

Initiative prepares reports on asthma management based on the best avail-
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able scientific evidence, encourages dissemination and implementation of

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the recommendations, and promotes international collaboration on asthma

research.
TE

Recommendations in this Pocket Guide present special challenges that must

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be taken into account to manage asthma in children during the first 5

AL

years of life, including difficulties with diagnosis, and efficacy and safety
of drugs and delivery systems. Approaches to these issues will vary
,

among populations based on socioeconomic conditions, genetic diversity,

DO

cultural beliefs, and differences in health care access and deliver.

The Global Initiative for Asthma offers a framework to achieve and

NO

maintain asthma control for most patients that can be adapted to local
TA

health care systems and resources. Program publications include:

Global Strategy for Asthma Management and Prevention (2008).

LT

Scientific information and recommendations for asthma programs.

ER

Pocket Guide for Asthma Management and Prevention (2008).

OR

Summary of patient care information for primary health care

professionals.
Pocket Guide for Asthma Management and Prevention in Children
5 Years and Younger (2009). Summary of patient care information
RE
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for pediatricians and other healthcare professionals

What You and Your Family Can Do About Asthma. An information
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booklet for patients and their families.

Publications are available from www.ginasthma.org.

U CE

This Pocket Guide has been developed from the Global Strategy for
Asthma Management and Prevention in Children 5 Years and Younger
.

(2009). Technical discussions of asthma, evidence levels, and specific cita-

tions from the scientific literature are included in the source document.

2
 WHAT IS KNOWN
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ABOUT ASTHMA?
PY
RI

Unfortunately asthma is the most common chronic disease of child-

hood and the leading cause of childhood morbidity from chronic disease
GH

as measured by absence from day care, emergency department visits, and

hospitalizations. There are special challenges that must be taken into
TE

account in managing asthma in children during the first 5 years of life.

D

Fortunately asthma in this young age group can be effectively treated

MA

and control can be achieved in most patients.

When asthma is under control children can:
TE

 Avoid troublesome symptoms night and day

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 Use little or no reliever medication


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Have productive, physically active lives

 Avoid serious attacks
,

Asthma causes recurring episodes of wheezing, breathlessness, chest

DO

tightness, and coughing, particularly at night or in the early morning.

NO

Asthma is a chronic inflammatory disorder of the airways. Chronically

inflamed airways are hyperresponsive; they become obstructed and air-
TA

flow is limited (by bronchoconstriction, mucus plugs, and increased

LT

inflammation) when airways are exposed to various risk factors.

Common risk factors for asthma symptoms in young children include
ER

exposure to allergens (such as those from house dust mites, animals,

cockroaches, fungi), exposure to tobacco smoke and biomass fuels, res-
OR

piratory (viral) infections and emotional stress.

Pharmacologic treatment to achieve and maintain control of asthma
RE

should take into account the safety of treatment, potential for adverse
PR

effects, and the cost of treatment required to achieve control.

Asthma attacks (or exacerbations) are episodic, but airway inflammation
OD

is chronically present.
For many patients, controller medication must be taken daily to prevent
U

symptoms, improve lung function, and prevent attacks. Reliever medica-

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tions may occasionally be required to treat acute symptoms such as

.

wheezing, chest tightness, and cough.

development of a partnership between the family/care giver and the

To reach and maintain asthma control in young children requires the

health care team.

3
 DIAGNOSING ASTHMA
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Making a definite diagnosis of asthma in children 5 years and younger is

PY

challenging because episodic respiratory symptoms such as wheezing and

cough are also common in children who do not have asthma, particularly in
RI

ma, and the younger the child, the greater the likelihood that an alterna-
those younger than 3 years. Not all young children who wheeze have asth-
GH

tive diagnosis may explain recurrent wheeze. These alternatives must be

TE

considered and excluded before an asthma diagnosis is made.

D

Alternative causes of recurrent wheezing, particularly in early infancy,

include infections (recurrent viral lower respiratory tract infections, chronic
MA

rhino-sinusitis, tuberculosis); congenital problems (cystic fibrosis, bronchopul-

TE

monary dysplasia, congenital malformation causing narrowing of the

intrathoracic airways, primary ciliary dyskinesia syndrome, immune deficien-
RI

cy, and congenital heart disease) and mechanical problems (foreign body
aspiration).
AL

A difficulty with diagnosing asthma in children 5 years and younger is that

, DO

the lung function measurements that are key to diagnosis in older children
and adults are not reliable in this age group.
NO

A trial of treatment with short-acting bronchodilators and inhaled glucocorti-

costeroids can help confirm an asthma diagnosis: look for marked clinical
TA

improvement during the treatment and deterioration when treatment is

stopped. The presence of atopy or allergic sensitization also increases the
likelihood that a wheezing child will have asthma.
LT

children can often be made based largely on symptom patterns and on a

ER

Taking all of these factors into account, a diagnosis of asthma in these young

careful clinical assessment of family history and physical findings (Table 1).
OR

Table 1. Is It Asthma?
Consider asthma if any of the following signs or symptoms are present:
RE

I Frequent episodes of wheezingmore than once a month.

PR

I Activity-induced cough or wheeze.

I Cough particularly at night during periods without viral infections.
OD

I Absence of seasonal variation in wheeze.

I Symptoms that persist after age 3.
I
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Symptoms occur or worsen in the presence of:

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Aeroallergens (house dust mites, companion animals, cockroach, fungi)

Exercise
.

Pollen
Respiratory (viral) infections
Strong emotional expression
Tobacco smoke
I The childs colds repeatedly go to the chest or take more than 10 days to clear up.
I Symptoms improve when asthma medication is given.

4
 CLASSIFICATION OF ASTHMA
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BY LEVEL OF CONTROL
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For all patients with a confirmed diagnosis of asthma, the goal of treatment
is to achieve and maintain control of the disease. However, assessing
GH

asthma control in children 5 years and younger is difficult, because health

care providers are almost exclusively dependent on the reports of the
TE

childs family members and caregivers who might be unaware of the pres-
D

ence of asthma symptoms, or of the fact that they represent uncontrolled

asthma. Additional information about asthma control may be gleaned from
MA

the childs need for reliever/rescue treatment (with increased use indicating
worsening control).
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Table 2 presents a working scheme to assess asthma control in children 5

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years and younger based on these two sources of information.

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Table 2. Levels of Asthma Control in Children 5 Years and Younger*

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Characteristic Controlled Partly Controlled Uncontrolled

(All of the following) (Any measure (Three or more of
present in any week) features of partly
NO

controlled asthma
in any week)
TA

Daytime symptoms: None More than twice/week More than twice/week

wheezing, cough , (less than twice/week, (typically for short (typically last minutes
LT

difficult breathing typically for short periods periods on the order or hours or recur, but
of on the order of of minutes and rapidly partially or fully relieved
ER

minutes and rapidly relieved by use of with rapid-acting

relieved by the use of a rapid-acting bronchodilators)
a rapid-acting bronchodilator)
OR

bronchodilator)

Limitations None Any Any

RE

of activities (child is fully active, (may cough, wheeze, (may cough, wheeze,
plays and runs without or have difficulty or have difficulty
limitation or symptoms) breathing during breathing during
PR

exercise, vigorous exercise, vigorous

play, or laughing) play, or laughing)
OD

Nocturnal None Any Any

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symptoms/awakening (including no nocturnal (typically coughs during (typically coughs during

coughing during sleep) sleep or wakes with sleep or wakes with
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cough, wheezing, cough, wheezing,

and/or difficult breathing) and/or difficult breathing)
.

Need for 2 days/week > 2 days/week > 2 days/week

reliever/rescue
treatment
* Any exacerbation should prompt review of maintenance treatment to ensure that it is adequete. Although patients
with current clinical control are less likely to experience exacerbations, they are still at risk during viral upper
respiratory tract infections and may still have one or more exacerbations per year.

5
MANAGEMENT AND
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PHARMACOLOGIC TREATMENT
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Control of asthma can be achieved in a majority of children 5 years and

younger with an intervention strategy that includes:
GH

A partnership between the childs family/caregivers and the health care team
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Avoidance of risk factors

A plan to assess, treat with appropriate pharmacologic therapy, and
D

monitor asthma control

MA

recognize an asthma attack and initiate treatment, recognize a severe

An action plan to enable the childs family members and caregivers to
TE
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episode, and identify when urgent treatment at a hospital (health care

facility) is required.
AL

Develop a Partnership
, DO

Family/Caregivers and Health Care Providers

With the help of everyone on the health care team, families/caregivers can
NO

be actively involved in managing asthma to prevent problems and enable

children to live productive, physically active lives. They can learn to:
TA

Help the child avoid risk factors

LT

Ensure that the child takes medications correctly

Understand the difference between controller & reliever medications
ER

Monitor asthma control status using symptoms

OR

Recognize signs that asthma is worsening and take action

Seek medical help as appropriate
RE

Education should be an integral part of all interactions between health care

PR

professionals and the family/caregivers of young children with asthma.

Using a variety of methodssuch as discussions (with a physician, nurse,
OD

outreach worker, counselor, or educator), demonstrations, written materials,

group classes, video or audio tapes, dramas, and family support groups
U

helps reinforce educational messages.

CE

caused by asthma, a written asthma action plan based on the levels of res-
For wheezy children 5 years and younger, when wheeze is suspected to be
.

piratory symptoms can be an effective tool to help family members/care-

givers improve and maintain control of the childs asthma.

6
 Identify and Reduce Exposure to Risk Factors
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To improve control of asthma and reduce medication needs, patients

toms (Table 3). However, many asthma patients react to multiple factors
should take steps to avoid the risk factors that cause their asthma symp-
PY
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that are ubiquitous in the environment, and avoiding some of these factors
completely is nearly impossible. Thus, medications to maintain asthma
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control have an important role because patients are often less sensitive to
these risk factors when their asthma is under control.
TE
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Table 3. Strategies for Avoiding Common Allergens and Pollutants

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Avoidance measures that improve control of asthma and reduce

TE

medication needs:
Tobacco smoke: Stay away from tobacco smoke. Parents and caregivers
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should not smoke.

AL

Drugs, foods, and additives: Avoid if they are known to cause symptoms.
, DO

Reasonable avoidance measures that can be recommended but have

not been shown to have clinical benefit:
House dust mites: Wash bed linens and blankets weekly in hot water and
NO
TA

dry in a hot dryer or the sun. Encase pillows and mattresses in air-tight cov-
ers. Replace carpets with hard flooring, especially in sleeping rooms.
(If possible, use vacuum cleaner with filters. Use acaricides or tannic acid to
LT

kill mitesbut make sure the patient is not at home when the treatment
ER

occurs.)

Animals with fur: Use air filters. (Remove animals from the home, or at least
OR

from the sleeping area. Wash the pet.)

Cockroaches: Clean the home thoroughly and often. Use pesticide spray
RE

but make sure the patient is not at home when spraying occurs.

Outdoor pollens and mold: Close windows and doors and remain indoors
PR

when pollen and mold counts are highest.

OD

Indoor mold: Reduce dampness in the home; clean any damp areas fre-
U

quently.
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.

7
ASSESS, TREAT, AND MONITOR ASTHMA
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The goal of asthma treatmentto achieve and maintain clinical control

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can be reached in most patients through a continuous cycle that involves

Assessing Asthma Control
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Treating to Achieve Control

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Monitoring to Maintain Control

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Assessing Asthma Control

Each patient should be assessed to establish his or her current treatment regi-
D

men, adherence to the current regimen, and level of asthma control. Current
MA

impairment (day and night symptoms, activity level impairment, need for res-
cue medications) and future risk (likelihood of acute exacerbation in the
TE

trolled, partly controlled, and uncontrolled asthma is provided in Table 2.

future) should both be addressed. A simplified scheme for recognizing con-
RI
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Treating to Achieve Control

For the treatment of asthma inhaled medications are preferred because
, DO

they deliver drugs directly to the airways where they are needed, resulting
in potent therapeutic effects with fewer systemic side effects.
NO

Devices recommended to deliver inhaled medication for children 5 years and

TA

younger include pressurized metered-dose inhalers (pMDIs) and nebulizers. Spacer

(or valved holding-chamber) devices make inhalers easier to use and reduce
LT

systemic absorption and side effects of inhaled glucocorticosteroids.

Among children in this young age group, inhaler technique may be poor
ER

and should be monitored closely.

OR

Teach family members/caregivers how to use the specific inhaler device(s)

prescribed for their child, as different devices need different inhalation techniques.
RE

Give demonstrations and illustrated instructions.

Ask family members/caregivers to show how their children use the
PR

inhalers at every visit.

OD

For each child, select the most appropriate device. In general:

U

Children younger than 4 years of age should use a pMDI plus a

CE

spacer with face mask, or a nebulizer with face mask.

Children aged 4 to 5 years should use a pMDI plus a spacer with
.

mouthpiece, or a pMDI plus a spacer with a face mask or, if nec-

essary, a nebulizer with face mask.
For children using spacers, the spacer must fit the inhaler.

8
 Information about use of various inhaler devices is found on the GINA
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Website (www.ginasthma.org).
PY

A variety of controller and reliever medications for asthma are available.

The recommended treatments discussed below are guidelines only. Local
RI

resources and individual patient circumstances should determine the spe-

GH

cific therapy prescribed for each patient.

All young children with asthma should be prescribed a reliever medica-

TE

tion to use as needed for quick relief of symptoms. (Parents and care-
D

givers should be aware of how much reliever medication the child is

trolled.) A rapid-acting inhaled 2-agonist is the recommended choice of

MA

usingregular or increased use indicates that asthma is not well con-

TE

reliever medication for most patients in this age group.

RI

If the childs asthma is not controlled with as-needed use of reliever med-
AL

controller treatment (Table 4).

ication, a low-dose inhaled glucocorticosteroid is the recommended initial
, DO

This initial treatment should be given for at least 3 months to establish its
effectiveness in reaching control. If at the end of this period the low dose
NO

of inhaled glucocorticosteroid does not control symptoms, and the child is

dose of glucocorticosteroid given in Table 5 may be the best option.

using optimal technique and is adherent to therapy, doubling the initial
TA

Addition of a leukotriene modifier to the low-dose inhaled glucocorticos-

LT

teroid may also be considered.

ER
OR
RE
PR
OD
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9
 Table 4. Asthma Management Approach Based on
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Control for Children 5 Years and Younger

Asthma education, Environmental control, and As needed rapid-acting 2-agonists
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Controlled Partly controlled Uncontrolled or only

partly controlled on
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on as needed on as needed
rapid-acting 2-agonists rapid- acting 2-agonists low-dose inhaled
GH

glucocorticosteroid*
TE
D

Controller options
MA

rapid-acting 2-agonists
TE

Continue as needed Low-dose inhaled Double low-dose inhaled

glucocorticosteroid glucocorticosteroid
RI
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Leukotriene modifier Low-dose inhaled

glucocorticosteroid plus
,

Leukotriene modifier
DO

*Oral glucocorticosteroids should be used only for treatment of acute severe exacerbations of asthma.
NO

Shaded boxes represent preferred treatment options.

TA

Table 5. Low Daily Doses* of Inhaled Glucocorticosteriods

for Children 5 Years and Younger
LT
ER

Drug g)
Low Daily Dose (

Beclomethasone dipropionate 100

OR

Budesonide MDI+spacer 200

Budesonide nebulized 500
RE

Ciclesonide NS
PR

Fluticasone propionate 100

OD

Mometasone furoate NS
U CE

Triamcinolone acetonide NS
.

* A low daily dose is defined as the dose which has not been associated with clinically adverse
effects in trials including measures of safety. This is not a table of clinical equivalence.
NS = Not studied in this age group.

10
 Monitoring to Maintain Control
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Ongoing monitoring is essential to maintain control and establish the low-
est step and dose of treatment to minimize cost and maximize safety.
PY

Typically, patients should be seen one to three months after the initial visit,
RI

and every three months thereafter. After an exacerbation, follow-up should

GH

be offered within two weeks to one month.

Adjusting medication:
If asthma is not controlled within one to three months by doubling the ini-
TE
D

tial dose of inhaled glucocorticosteroids, assess and monitor the childs

inhalation technique, compliance with medication regimen, and avoid-
MA

ance of risk factors.

If control is maintained for at least 3 months, decrease treatment to the
TE

least medication necessary to maintain control. Monitoring is still neces-

RI

sary even after control is achieved, as asthma is a variable disease;

AL

treatment has to be adjusted periodically in response to loss of control as

indicated by worsening symptoms or the development of an exacerbation.
, DO

Asthma symptoms remit in a substantial proportion of children 5 years and

younger, and some children have symptoms only during certain seasons of
NO

the year. It is recommended that the continued need for asthma treatment
in children under age 5 should be regularly assessed (every 3-6 months). If
TA

asthma therapy is discontinued, a follow-up visit should be scheduled 3-6

weeks later to verify that the remission of symptoms persists.
LT

Consult with an asthma specialist when other conditions complicate asthma,

ER

if the child does not respond to therapy, or if asthma remains uncontrolled.

OR

Approach to the Child with Intermittent Wheezing Episodes

Intermittent episodic wheezing of any severity may represent unrecognized
RE

uncontrolled asthma, an isolated viral-induced wheezing episode, or an

ommended includes a dose of rapid-acting inhaled 2-agonist every 46

episode of seasonal or allergen-induced asthma. The initial treatment rec-
PR

hours as needed for a day or more until symptoms disappear.

OD

If a detailed history suggests the diagnosis of asthma, and wheezing

U

episodes are frequent (e.g., 3 in a season), regular controller treatment

CE

should be initiated. Regular controller treatment may also be indicated in a

child with less frequent, but more severe, episodes of viral-induced wheeze.
Where the diagnosis is in doubt, and when rapid-acting inhaled 2-ago-
.

nist therapy needs to be repeated more frequently than every 6-8 weeks, a
diagnostic trial of regular controller therapy should be considered to con-
firm whether the symptoms are due to asthma.

11
Manage Acute Exacerbations
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Exacerbations of asthma (asthma attacks) are acute episodes of deteriora-

tion in symptom control that are sufficient to cause distress or risk to health
PY

necessitating a visit to a health care provider or requiring treatment with sys-

temic glucocorticosteroids.
RI

Do not underestimate the severity of an attack (Table 6); severe asthma

GH

attacks may be life threatening. Early symptoms may include any of the
TE

following:
D

An increase in wheeze and shortness of breath

An increase in coughing, especially nocturnal cough
MA

Lethargy or reduced exercise tolerance

TE

Impairment of daily activities, including feeding

A poor response to reliever medication
RI
AL

Upper respiratory symptoms frequently precede the onset of an asthma

exacerbation.
, DO

Home Management
NO

A health care provider may recommend steps for the family/caregiver to

care for an asthma attack at home:
Initiate treatment with two puffs of inhaled rapid-acting 2-agonist, given
.
TA

one puff at a time via a mask or spacer device.

LT

Observe the child and maintain a restful atmosphere for one hour or
ER

more
Seek medical attention the same day if inhaled bronchodilator is
OR

required for symptom relief more than every 3 hours or for more than
24 hours.
RE

Oral glucocorticosteroid treatment by family/caregivers in the home man-

PR

agement of asthma exacerbations in children should be considered only where

the physician is confident that this medication will be used appropriately.
OD

Immediate medical attention should be sought .

U

inhaled 2-agonists over the course of hours

CE

For children younger than 1 year requiring repeated rapid-acting

.

If the child is acutely distressed

If the period of relief after a dose of inhaled 2-agonist becomes pro-

If the symptoms are not relieved promptly by inhaled bronchodilator

gressively shorter

12
 Table 6. Initial Assessment of Acute Asthma in Children
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Five Years and Younger

Severea
PY

Symptoms Mild

Altered consciousness No Agitated, confused or

RI

drowsy
GH

Oximetry on presentationb 94% < 90%

TE

(SaO2)
D

Talks inc Sentences Words

MA

Pulse rate < 100 bpmd > 200 bpm (0-3 years)
> 180 bpm (4-5 years)
TE

Central cyanosis Absent Likely to be present

RI
AL

Wheeze intensity Variable May be quiet

, DO

a Any of these features indicates a severe asthma exacerbation

b Oximetry performed before treatment with oxygen or bronchodilator
c The normal developmental capability of the child must be taken into account.
NO

d bpm = beats per minute.

TA

dosing with rapid-acting inhaled 2-agonists, with or without the addition

LT

If a severe exacerbation fails to resolve in 1 to 2 hours in spite of repeated

ER

for observation and further treatment (Table 7).

of oral glucocorticosteroids, refer the child to the hospital (or health center)
OR

Other indications for referral to the hospital/health center include:

RE

respiratory arrest or impending arrest

PR

lack of supervision in the home

OD

recurrence of signs of severity within 48 hours of the initial exacerba-

tion (particularly if treatment with systemic glucocorticosteroids has
U

been given).
CE

For children younger than 2 years, early medical attention should be

.

sought as the risk of dehydration and respiratory fatigue is increased.

13
 Table 7. Indications for Immediate Referral to Hospital
CO

ANY of the following:

PY

short-acting 2-agonist within 1-2 hours

No response to three (3) administrations of an inhaled
RI

Tachypnea despite 3 administrations of an inhaled short-acting 2-agonist

GH

(Normal respiratory rate < 60 breaths per minute in children 0 2 months;

TE

< 50 in children 2 12 months; < 40 in children 1 5 years)

D

Child is unable to speak or drink or is breathless

MA

Cyanosis
TE

Subcostal retractions
Oxygen saturation when breathing room air < 92%
RI
AL

Social environment that impairs delivery of acute treatment;

caregivers unable to manage acute asthma at home
, DO

Asthma attacks require prompt treatment (Table 8):

NO

Oxygen delivered by face mask given at hospital (health center) if the

patient is hypoxemic (achieve O2 saturation above 94%).
Inhaled rapid-acting 2-agonists in adequate doses are essential (two
TA
LT

puffs at 20-minute intervals for an hour).

ER

Failure to respond to bronchodilator therapy at 1 hour, or earlier if the

child deteriorates, requires urgent admission to hospital and a short
OR

course of oral glucocortiocosteroids.

Children prescribed maintenance therapy with inhaled glucocorticos-
RE

teroids or leukotriene modifier or both should continue to take the pre-

scribed dose during and after an attack.
PR

Therapies not recommended for treating attacks include:

OD

Sedatives.
U

Mucolytic drugs.
CE

Chest physical therapy/physiotherapy.

.

Epinephrine (adrenaline) may be indicated for acute treatment of ana-

phylaxis and angioedema but is not indicated during asthma attacks.
Intravenous magnesium sulphate has not been studied in young children.

14
 Table 8: Initial Management of Acute
CO
Severe Asthma in Children 5 Years and Younger*

Therapy Dose and Administration

PY

Supplemental Deliver by 24% face mask (flow set to manufacturers

RI

oxygen instructions, usually 4L/minute)

GH

Maintain oxygen saturation above 94%

TE

2-agonist
Short-acting 2 puffs salbutamol by spacer,
or
D

2.5 mg salbutamol by nebulizer

Every 20 minutes for first hoursa
MA
TE

Ipratropium 2 puffs every 20 minutes for first hour only

RI

Oral prednisolone
AL

Systemic (1-2 mg/kg daily for up to 5 days)

glucocorticosteroids or
,

Intravenous methylprednisolone
DO

1 mg/kg every 6 hours on day 1;

every 12 hours on day 2; then daily
NO

Consider in ICU: loading dose

Aminophyllineb 6-10mg/kg lean body weight
TA

Initial maintenance: 0.9 mg/kg/hour

Adjustment according to plasma theophylline levels
LT

Oral 2-agonists
ER

No

Long-acting 2-agonist
OR

No

a If inhalation is not possible an intravenous bolus of 5 g/kg given over 5 minutes, followed by
RE

continuous infusion of 5 g/kg/hour.

The dose should be adjusted according to clinical effect and side effects84.
PR

b Loading dose should not be given to patients already receiving theophylline.

OD
U CE
.

15
 Follow up:
CO

Before discharge from the emergency department or hospital, the condition

of the patient should stable, e.g., out of bed and able to eat and drink
PY

without problem. Family/caregivers should receive:

RI

Instruction on recognition of signs of recurrence and worsening of asth-

GH

ma. The factors that precipitated the exacerbation should be identified

and strategies for future avoidance of these factors implemented
TE

A written individualized action plan including details of accessible

emergency services
D
MA

A supply of bronchodilator and, where applicable, the remainder of

the course of oral or inhaled glucocorticosteroids or leukotriene modifier
TE

Careful review of inhaler technique

RI

Further treatment advice

AL
,

A follow-up appointment within 1 week and another within 1-2 months

DO

depending on the clinical, social, and practical context of the exacer-

bation
NO
TA
LT
ER
OR
RE
PR
OD
U CE
.

16
 .
U CE
OD
PR
RE
OR
ER
LT
TA
NO
, DO
AL
RI
TE
MA
D
TE
NOTES GH
RI
PY
CO
 The Global Initiative for Asthma is supported by educational grants from:
CO
PY
RI
GH
TE
D
MA
TE
RI
AL
, DO
NO
TA
LT
ER
OR
RE
PR
OD
U
CE
.

Copies of this document are available at

www.ginasthma.org
www.us-health-network.com