Use a Stepwise Approach for Very Mild and Mild Asthma in Kids

Management of very mild and mild asthma in kids is in the spotlight...due to updated guidance from the Canadian Paediatric Society.

Disease severity is based on the meds needed to control asthma symptoms when other factors (inhaler technique, etc) are ruled out.

For example, kids have “VERY mild asthma” if symptoms are controlled with only a prn rescue inhaler (salbutamol, etc)...but patients have “mild asthma” if they also need a regular low-dose inhaled corticosteroid.

Use this as an opportunity to identify patients with signs of poorly controlled asthma who may need their meds reviewed.

Evaluate asthma control. Review signs of poor asthma control.

For example, the patient is considered uncontrolled if they need more than two doses of rescue inhaler per week, daytime symptoms occur more than twice weekly, or nighttime symptoms occur more than once weekly.

Next consider risk of exacerbations, since patients with well-controlled asthma can still be at higher risk of exacerbations.

For example, patients previously needing oral steroids for an asthma exacerbation are at higher risk for future exacerbations.

Also keep track of rescue inhaler refills...needing more than 2 rescue inhaler refills per year is another indicator of increased exacerbation risk, even if the patient has well-controlled asthma.

Manage current meds. Recommend adding a regularly scheduled inhaled corticosteroid (ICS) for patients with very mild asthma who show signs of uncontrolled asthma or are at higher risk of exacerbations.

Reassure patients and their families that inhaled corticosteroids have a small or no impact on growth in children. For example, long-term studies show a maximum of 1 to 2 cm decrease in final height.

Consider budesonide/formoterol (Symbicort) prn for patients 12 years and up with a lower exacerbation risk who continue to struggle with regular ICS use, even after several attempts of education and support.

Point out that this single inhaler will open airways quickly with formoterol...plus the inhaled steroid will reduce inflammation.

Save montelukast (Singulair) as a second-line option for patients who can’t or won’t use an ICS. But explain that it’s less effective and can cause psychiatric side effects (anxiety, sleep disturbances, etc).

Use our resources, Stepwise Pharmacotherapy of Pediatric Asthma and Biologics and Inhalation Medications for Asthma, to learn more about how to assess patients, adjust treatment, and review treatment response.

• Algorithm: Stepwise Pharmacotherapy of Pediatric Asthma
• Chart: Biologics and Inhalation Medications for Asthma