Patient education: Asthma treatment in children (Beyond the Basics)

ASTHMA TREATMENT OVERVIEW — Asthma is a common lung disease affecting millions of people worldwide. It is characterized by narrowing of the airways in the lungs (figure 1). Symptoms of asthma include wheezing, coughing, chest tightness, and shortness of breath. These symptoms tend to come and go and are related to the degree of airway narrowing in the lungs. Different things can trigger symptoms in people with asthma, including viral illnesses (eg, the common cold), allergens, exercise, medications, or environmental conditions.

The optimal treatment of asthma in children depends upon a number of factors, including the child's age, the severity and frequency of asthma attacks (also called "exacerbations"), and the ability to properly use the prescribed medications. In most cases, medications can control symptoms, allowing the child to participate fully in all activities, including sports.

Successful treatment of asthma involves three components:

●Identifying and avoiding asthma triggers

●Regularly monitoring asthma symptoms and lung function

●Understanding how and when to use medications to treat asthma

This topic discusses the treatment of asthma in children younger than 12 years. The symptoms and diagnosis of asthma, as well as instructions for using asthma inhalers and avoiding things that trigger symptoms, are discussed separately. (See "Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)" and "Patient education: Asthma inhaler techniques in children (Beyond the Basics)" and "Patient education: Trigger avoidance in asthma (Beyond the Basics)".)

Children older than 12 years are treated with asthma medications and doses similar to that of adults. Information about asthma in adolescents and adults is also available separately. (See "Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient education: How to use a peak flow meter (Beyond the Basics)" and "Patient education: Inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma and pregnancy (Beyond the Basics)".)

WHAT CAN WE DO ON OUR OWN? — There are several things you can do to help keep your child's asthma well controlled. These include learning about the condition, understanding how and when to give medications (and when to seek emergency help), identifying and avoiding things that make your child's symptoms worse, keeping track of symptoms, and maintaining regular communication with your child's health care provider and school.

Education — It's important to make sure that you learn and understand how to recognize asthma symptoms in your child and when to give medication. Keeping an asthma "action plan" can help prepare you to treat symptoms when they happen. (See 'Action plan' below.)

It also helps to develop a strong relationship with your child's health care provider so you feel comfortable asking questions and sharing your concerns. Ideally, you, your child, and the provider will work together to make decisions about treatment. In addition, it is important to communicate regularly with your child's school (and school nurse, if possible) so they are informed about your child's condition and treatment plan.

Monitoring asthma over time — Successful management of asthma requires monitoring the condition over time. This involves being aware of the frequency and severity of your child's symptoms as well as anything that seems to trigger them (such as exercise, cold weather, exposure to allergens). You may also need to measure your child's lung function. (See 'Controlling asthma triggers' below and 'Measurement of lung function' below.)

Asthma diary — Your child's provider may recommend keeping a daily asthma diary when symptoms are not well controlled or when starting a new treatment. In the diary, you can keep track of when your child has symptoms (such as coughing, wheezing, or shortness of breath) and which medications your child took and when (form 1). (See 'Measurement of lung function' below.)

Your child's provider may also suggest completing a self-assessment form periodically, such as before a routine visit (form 2). This type of form can be used to help determine whether your child's treatment plan needs to be adjusted.

Measurement of lung function — Monitoring lung function involves measuring your child's spirometry (ie, the rate at which you can exhale). When asthma is causing a person's airways to narrow, air flows more slowly out of the lungs, causing the spirometry measurement to be lower. This test requires a high level of cooperation and the ability to make and keep a tight seal on a mouthpiece. Typically, children can do this when they are about six years old.

Depending on their age and ability, your child may get lung function testing during visits with their provider. In addition, your child's provider might suggest checking their breathing at home periodically. This is done by having the child blow into a device, either a peak flow meter or an electronic handheld spirometer. (See "Patient education: How to use a peak flow meter (Beyond the Basics)" and "Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)", section on 'Spirometry testing'.)

Lung function tests are used to monitor your child's response to medication and help guide decisions about treatment.

Action plan — An asthma "action plan" is a form or document that your child's provider can help you put together; it includes instructions about how to monitor symptoms and what to do when they happen. Asthma action plans are available for children (form 3), for adults (form 4), and for school (Student Asthma Action Card). An action plan can tell you when to add or increase medications, when to call your child's provider, and when to get immediate emergency help. This can help you know what to do in the event of an asthma attack. Different people can have different action plans, and your child's action plan will likely change over time.

Action plans usually include three categories, based on your child's symptoms and/or peak expiratory flow (PEF) (see 'Measurement of lung function' above):

●Green – Green means the lungs are functioning well. When symptoms are not present or are well controlled, your child can continue their regular medicines and activities.

●Yellow – Yellow means your child's airways are somewhat narrowed, making it difficult to move air in and out; asthma symptoms may be more frequent or more severe. This is usually treated by adding a "quick-relief" medication to use when symptoms flare up; it may also involve changing or increasing daily controller medications. You should change or increase your child's medication according to the plan that was discussed with their provider. If your child does not improve after following the steps in their "yellow" action plan, call their provider to find out what to do next.

●Red – Red means your child's airways are severely narrowed and symptoms are severe; this requires immediate treatment with a quick-relief inhaler according to your child's action plan. Your child should also be evaluated by a medical professional.

When to call for emergency help — It's important to know when to get emergency help for a severe asthma attack, for example, if medications do not work quickly to relieve your child's symptoms. Severe asthma attacks may lead to death if not treated promptly.

In most areas of the United States and Canada, you can call 9-1-1 for emergency medical assistance. You should not attempt to drive your child to the hospital yourself, and you should not ask someone else to drive. Calling for emergency help is safer than driving for two reasons:

●From the moment emergency personnel arrive, they can begin evaluating and treating your child. If you drive to the hospital, treatment cannot begin until your child arrives at the emergency department.

●If a dangerous complication of asthma occurs on the way to the hospital, emergency personnel will be able to treat the problem immediately.

Following an asthma attack, most children are given an oral steroid medication (for example, a 3- to 10-day course of prednisone or a single or two-day course of dexamethasone). This treatment helps to decrease the swelling and mucus production in the lungs and reduces the risk of a second asthma attack.

Controlling asthma triggers — The factors that set off or worsen asthma symptoms are called "triggers." Identifying and avoiding asthma triggers are essential to keeping symptoms under control.

Common asthma triggers generally fall into several categories:

●Allergens (including dust mites, pollen, mold, cockroaches, mice, cats, and dogs)

●Respiratory infections, such as the common cold, the flu, or coronavirus disease 2019 (COVID-19)

●Irritants (such as tobacco smoke, chemicals, and strong odors or fumes)

●Exercise or other physical activity

●Cold air

After identifying potential asthma triggers, you will need to work with your child's provider to develop a plan to deal with the triggers. If possible, the child should completely avoid or limit exposure to the trigger (for example, prohibit smoking in your home, remove carpets from your child's bedroom, or find a new home for your furry pet).

While some triggers can be avoided, your child should not avoid physical activity. Exercise is healthy and encouraged for all children, including those with asthma. An asthma action plan should include steps to prevent and treat exercise-related symptoms.

Trigger avoidance is discussed in detail separately. (See "Patient education: Trigger avoidance in asthma (Beyond the Basics)".)

Regular medical appointments — Children with asthma need to see their health care provider regularly. This typically means appointments every one to six months. At these visits, the provider will ask about the severity and frequency of your child's asthma symptoms or any exacerbations to assess how well their treatment is working.

The medications used to treat asthma in children vary according to the child's age and ability to properly use the medications, the severity of symptoms, and the level of asthma symptom control. If control has been adequate for at least three months, your health care provider may recommend that the asthma medication dose may be decreased or changed. If control is not adequate, the medication schedule, delivery technique, and trigger avoidance will be reviewed, and the medication dose may be increased or additional medication prescribed.

Outside of regularly scheduled appointments, it's important to let your child's provider know if their asthma symptoms get worse at any point in time. If this happens, they will review your child's medications, ensure that they are avoiding triggers and using their inhaler(s) properly, and suggest changes in medications or dosing as appropriate.

APPROACH TO ASTHMA TREATMENT — The approach to asthma treatment depends on your child's age and ability as well as the frequency and severity of their symptoms. Asthma is typically categorized as "intermittent" or "persistent." Your child's health care provider will work with you to review your child's symptoms and adjust your treatment plan over time.

Intermittent asthma — Children with intermittent asthma have infrequent symptoms that are typically mild. Specifically, they have the following characteristics:

●Daytime symptoms occur two or fewer days per week

●Asthma does not interfere with daily activities

●Nighttime symptoms do not awaken the child (for children 4 years old and younger) or awaken the child two or fewer times per month (for children age 5 to 11 years)

●Oral steroids are needed no more than once per year to treat increased symptoms

If your child's symptoms are triggered only by exercise (called "exercise-induced asthma" or, more accurately, "exercise-induced bronchoconstriction"), they may be considered to have intermittent asthma. However, symptoms during exercise can also happen in people with persistent asthma (see 'Persistent asthma' below). Exercise-induced asthma is discussed in more detail separately. (See "Patient education: Exercise-induced asthma (Beyond the Basics)".)

Persistent asthma — Children with persistent asthma have symptoms regularly. There may be days when activities are limited due to asthma symptoms, and the child may be awakened from sleep. Lung function is usually normal between episodes but becomes abnormal during an asthma attack.

Based on the frequency of symptoms as well as the measurement of lung function, your child's provider will classify their persistent asthma as mild, moderate, or severe. This will help determine the best treatment plan.

To determine whether asthma is mild, moderate, or severe, the provider will consider how many days per week your child has one or more of the following:

●Symptoms such as cough, wheeze, and shortness of breath

●Nighttime asthma symptoms that awaken your child from sleep

●Symptoms that need treatment with a bronchodilator (reliever medication)

●Symptoms that affect your child's ability to participate in normal activities

The provider will also take into consideration the number of times per year that oral steroids are required to treat increased symptoms, as well as your child's lung function if this has been measured.

Consultation with an asthma specialist (a pulmonologist or allergist) is recommended for children who have moderate or severe persistent asthma, as well as those ages four years or younger who have any form of persistent asthma.

ASTHMA QUICK-RELIEF MEDICATIONS — Quick-relief medications are used to relieve asthma symptoms when they happen.

Short-acting beta agonists — Short-acting beta agonists (SABAs) are a type of "bronchodilator" medication. They relieve symptoms rapidly by temporarily relaxing the muscles around narrowed airways, allowing more air to get through. These medications are sometimes referred to as "quick-acting relievers" or "rescue medication." Children with intermittent asthma, the mildest form of asthma, will require these medications only occasionally. Although they work quickly to relieve symptoms, they do not prevent future attacks, because they do not work on the airway inflammation.

SABAs include albuterol (brand names: ProAir HFA, Proventil HFA, Ventolin HFA) and levalbuterol (Xopenex HFA). These are available in "generic" form in addition to the various brand names. "HFA" means the medicine comes in a metered dose inhaler (MDI). SABAs can also be given with a device called a nebulizer. (See 'Inhaler versus nebulizer' below.)

SABAs are meant to be used as needed for relief of asthma symptoms. There is no benefit to using them on a regular, scheduled basis, and it can actually be harmful to do so. If your child is consistently having symptoms on more than two days per week, you should discuss the treatment plan with their health care provider. Other medications are more effective for controlling persistent symptoms. (See 'Asthma controller medications' below.)

Some children feel shaky, have an increased heart rate, or become hyperactive after using a SABA. These side effects are typically most noticeable within the first 30 minutes after taking the medication, then decrease. If they persist, contact your health care provider.

Inhaler versus nebulizer — As mentioned above, SABAs can be given by inhaler or nebulizer. The best choice for your child will depend on their age and abilities:

●MDIs dispense liquid or fine powder medications, which mix with the air that is breathed into the lungs (figure 2). In children, the inhaler should be used along with a spacer device (figure 3) to maximize the amount of medication that reaches the lungs. Younger children can also use a special mask that attaches to the spacer to help them inhale the medication without needing to maintain a tight seal with their mouth on the spacer.

It is preferable to have the child use the inhaler when they are awake, calm, and not crying. Your child's inhaler will come with specific instructions for preparation and use; more information about inhaler techniques is also available separately. (See "Patient education: Asthma inhaler techniques in children (Beyond the Basics)".)

●Nebulizers use compressed air to turn medication into a fine mist that is inhaled through a mask or mouthpiece (figure 3). When a mask is used, it should be placed snugly over the child's face; moving the mask away from the face even slightly can reduce the amount of medication that gets to the lungs. Nebulizers may be preferred for children who are unable to use an MDI with spacer.

ASTHMA CONTROLLER MEDICATIONS — Children with persistent asthma need to take medication on a daily basis to keep their asthma under control, even if they do not have symptoms every day. The medications used for this are called "long-term controller" medications. (See 'Persistent asthma' above.)

Some controller medications come in an inhaler, while others are taken as a pill, liquid, or granules. If your child takes a controller medication, the type and dose will depend on how frequently they have symptoms and how severe they are. Some children need to take more than one controller medication.

While controller medications help to reduce the frequency of asthma attacks, you (or your child) will still need to keep quick-relief medications on hand in order to treat symptoms if they do happen. (See 'Asthma quick-relief medications' above.)

Inhaled steroids — Inhaled steroids (also known as glucocorticoids or corticosteroids) decrease inflammation (swelling) of the airways over time. The steroids used to treat asthma are entirely different from the ones athletes sometimes take to build muscle. Daily treatment with an inhaled steroid reduces the frequency of symptoms (and the need to use short-acting medication for symptom relief), improves quality of life, and decreases the risk of serious asthma attacks. An inhaled steroid may also be prescribed for intermittent (occasional) use, such as at the onset of a viral respiratory infection, in children with intermittent or mild persistent asthma.

Inhaled steroids can be taken with an inhaler or a nebulizer (figure 3).

Side effects — Unlike liquid or tablet steroid medications that are taken by mouth, very little of the inhaled steroid is absorbed through the airways into the bloodstream, and there are few side effects. As the dose of inhaled steroids is increased, more of the medication is absorbed into the bloodstream, and the risk of side effects increases. While the overall risk is still small regardless of dose, your child's provider will prescribe the lowest possible dose of inhaled steroids to control symptoms.

●Thrush – The most common side effect of inhaled steroids is a fungal infection in the mouth called "oral candidiasis," also known as thrush. This can usually be prevented by having your child rinse their mouth and gargle with water immediately after using their inhaler. If your child uses a metered dose inhaler (MDI), it may also help to use a spacer device; this helps deliver medication directly to the lungs, with less deposited in the mouth.

●A hoarse voice or sore throat – These are less common side effects of inhaled steroids; they can often be managed by switching to a different medication or type of inhaler.

●Impact on growth – Parents sometimes worry that regular use of inhaled steroids will affect their child's growth. While some studies have suggested that steroids can lead to a modest reduction from predicted adult height, the difference was small.

While many parents are concerned about the potential side effects of inhaled steroids, it is important to keep in mind that untreated asthma can also cause harm, including preventing the child from participating in activities and increasing the risk of a serious asthma attack.

The goal of treatment is to use the lowest possible dose of inhaled steroids while maintaining good asthma control and minimizing the risk of serious asthma attacks. This usually means monitoring symptoms and either increasing the dose of inhaled steroids or adding other medications if symptoms are not well controlled.

Inhaled steroids plus a long-acting beta agonist — If asthma is not well controlled with daily inhaled steroids, your child's provider may suggest adding a medication called a long-acting beta agonist (LABA). LABAs work for 12 or more hours, longer than short-acting beta agonists (SABAs); they include formoterol, salmeterol, and vilanterol.

LABAs should be used only in combination with an inhaled steroid; they should not be used alone. If your child needs a LABA, it will come in a combination inhaler that also contains an inhaled steroid.

Inhaled steroids plus a long-acting muscarinic antagonist — A long-acting muscarinic antagonist (LAMA; eg, tiotropium) is used in addition to or as an alternative to a LABA when asthma is not well controlled on inhaled steroids. Maximum benefits may take up to four to eight weeks to occur. Tiotropium causes minimal side effects.

Leukotriene modifiers — Leukotriene modifiers are another type of long-term controller medication. They work by opening narrowed airways, decreasing inflammation, and decreasing mucus production. The leukotriene modifier montelukast (brand name: Singulair) is taken by mouth once daily and is available as a chewable pill or granules that can be taken directly or mixed into certain soft foods.

Leukotriene modifiers can be used in addition to inhaled steroids in children who have more severe and/or difficult-to-control asthma; they can also help in children in whom exercise triggers asthma symptoms. (See "Patient education: Exercise-induced asthma (Beyond the Basics)", section on 'Leukotriene modifiers'.)

While generally not as effective as inhaled steroids, leukotriene modifiers might be an alternative option for children with mild, persistent asthma who have difficulty using an inhaler.

There are concerns that montelukast might cause mental health side effects like mood changes, aggressive behavior, or, rarely, even suicide. Tell your child's health care provider right away if any changes in mood or behavior occur after starting this medication.

Controller medications for more severe asthma — Children with more severe persistent asthma that is difficult to control may need to take other medications in addition to those described above. These include:

Biologics — "Biologic" medications include omalizumab (brand name: Xolair), mepolizumab (brand name: Nucala), and dupilumab (brand name: Dupixent). These may be considered in certain situations for children at least six years of age whose asthma has specific characteristics and is not well controlled with other medications.

MEDICATIONS FOR ASTHMA ATTACKS — In general, an asthma attack or "exacerbation" refers to an increase in symptoms above one's usual level in a way that interferes with normal activities. Asthma attacks can come on over a few days or can happen suddenly. Some children have periodic, mild asthma attacks that can be treated at home, while others have severe asthma attacks that require emergency medical services. Review your child's asthma action plan regularly to make sure you know exactly what medicines to give and what dose and when your child's health care provider wants you to call the office or call for emergency help. (See 'Action plan' above.)

Quick-relief medication — In most cases, treating an asthma attack involves using a short-acting beta agonist (SABA) such as albuterol. If your child uses an inhaler, the usual dose is 2 to 4 inhalations (puffs). If your child still has symptoms after 10 to 20 minutes, they can take another dose. (See 'Short-acting beta agonists' above.)

Oral steroids — Oral steroids are typically used if two treatments with a SABA do not fully resolve symptoms. The appropriate dose depends on the child's weight. Your provider may instruct you to continue giving your child periodic doses of the SABA after giving oral steroids.

After giving oral steroids, contact your child's provider right away for advice on what to do next. They can tell you whether you should bring your child to the office or call for an ambulance to take you to the emergency department. (See 'When to call for emergency help' above.)

WHERE TO GET MORE INFORMATION — Your child's health care provider is the best source of information for questions and concerns related to your child's medical problem.

This article will be updated as needed on our website (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for health care professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Asthma in children (The Basics)
Patient education: Avoiding asthma triggers (The Basics)
Patient education: How to use your child's metered dose inhaler (The Basics)
Patient education: How to use your child's dry powder inhaler (The Basics)
Patient education: Inhaled corticosteroid medicines (The Basics)
Patient education: Medicines for asthma (The Basics)
Patient education: Breathing tests (The Basics)
Patient education: Enterovirus D68 (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Asthma symptoms and diagnosis in children (Beyond the Basics)
Patient education: Asthma inhaler techniques in children (Beyond the Basics)
Patient education: Trigger avoidance in asthma (Beyond the Basics)
Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)
Patient education: How to use a peak flow meter (Beyond the Basics)
Patient education: Inhaler techniques in adults (Beyond the Basics)
Patient education: Asthma and pregnancy (Beyond the Basics)
Patient education: Exercise-induced asthma (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Acute asthma exacerbations in children younger than 12 years: Emergency department management
Acute severe asthma exacerbations in children younger than 12 years: Intensive care unit management
An overview of asthma management
Evaluation of wheezing in infants and children
Aspirin-exacerbated respiratory disease
Asthma in children younger than 12 years: Management of persistent asthma with controller therapies
Asthma in children younger than 12 years: Initial evaluation and diagnosis
Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms
Exercise-induced bronchoconstriction
Natural history of asthma
Nocturnal asthma
Peak expiratory flow monitoring in asthma
Risk factors for asthma
Subcutaneous immunotherapy (SCIT) for allergic rhinoconjunctivitis and asthma: Indications and efficacy
The impact of breastfeeding on the development of allergic disease
Delivery of inhaled medication in children
Use of medication nebulizers in children

The following organizations also provide reliable health information.

●The National Library of Medicine

(https://medlineplus.gov/healthtopics.html)

●American College of Allergy, Asthma, and Immunology

(https://acaai.org/news/allergists-the-doctors-you-didnt-know-could-help-you-with-your-asthma/)