Suggested approach to initial asthma therapy in infants and children <4 years of age

This table illustrates a simplified suggested approach for initiating asthma therapy in patients who have never taken any form of long-term controller therapy. The degree of severity while not on long-term controller medications determines which "step" or level of initial therapy is needed. Severity is determined by current impairment and future risk of exacerbations. Risk factors for exacerbations include poor asthma symptom control, a history of asthma exacerbation on the current regimen, tobacco smoke exposure, environmental allergen exposure if sensitized, previous intubation or intensive care unit stay for asthma, obesity, food allergy, chronic rhinosinusitis, and poor adherence/inhaler technique. Other factors, including the risk of developing persistent asthma, are also taken into consideration in children under 5 years of age. Consultation with an asthma specialist is recommended if step 3 or higher is required.

Patients should be reevaluated after initiation of controller therapy to determine its effectiveness. A reasonable interval is 2 to 4 weeks for patients diagnosed with moderate-to-severe persistent asthma and 4 to 6 weeks for children with mild persistent asthma. At follow-up visits, check adherence and inhaler technique and assess for environmental factors and comorbid conditions.

Additional strategies for initial asthma treatment may be found in UpToDate asthma treatment content. Dosing information can be found in separate dosing tables for SABA and ICS. For additional information, refer to UpToDate content on initial and ongoing treatment of asthma in children.