Table 1 : Stepwise approach for managing asthma in children up to age 4
INTERMITTENT ASTHMA
PERSISTENT ASTHMA ( Daily Medication )
Consult with asthma specialist if Step 3 care or higher is required . Consider consultation at Step 2
Step 6
Step 1 Preferred : Low-dose ICS
Preferred : SABA prn
Step 2 Preferred : Medium-dose ICS
Alternative : cromolyn or montelukast
Step 4 Preferred : High-dose ICS
Step 3 Preferred : Medium-dose ICS + either LABA or montelukast
Step 5 Preferred : High-dose ICS
+ either LABA or montelukast
+ either LABA or montelukast
Alternative : Oral systemic corticosteroids
Assess control : check adherence , inhaler technique , and environmental control . Step up if needed and step down if possible ( if well-controlled at least three months ).
Each Step : Patient / parent education and environmental control
KEY ( alphabetical order )
� ICS = inhaled corticosteroid
� LABA = inhaled long-acting beta 2 -agonist
� SABA = inhaled short-acting beta 2 -agonist
QUICK RELIEF MEDICATION ( all patients )
� SABA as needed for symptoms ; intensity of treatment depends on severity of symptoms .
� With viral respiratory infection : SABA every 4 to 6 hours up to 24 hours ( longer with physician consult ).
� Frequent use of SABA may indicate the need to step up treatment .
NOTES
� This approach is meant to assist , not replace , the clinical decision making required to meet individual patient needs .
� If an alternative treatment is used and the response is inadequate , discontinue it and use the preferred treatment before stepping up .
� If a clear benefit is not observed within 4 to 6 weeks and the patient / family medication technique and adherence are satisfactory , consider adjusting the therapy or alternative diagnosis .
� Studies on children up to age 4 are limited . Step 2 preferred therapy is based on Evidence A . All other recommendations are based on expert opinion and extrapolation from studies in older children .
Source : Adapted from the National Asthma Education and Prevention Program . Expert Panel Report 3 : Guidelines for the Diagnosis and Management of Asthma , Full Report 2007 .
Asthma - 6