Childhood Asthma Treatment Options

Cope & Control

Take an active, flexible approach to helping your child become symptom-free. Parents may struggle at times to establish control of their child's asthma, or may be unsure whether or not they are doing a good enough job. That's understandable. "Asthma is a diverse, changing condition. It's like trying to hit a moving target," says Bernard S. Zeffren, M.D., presidentelect of the Florida Allergy, Asthma & Immunology Society.

But new asthma treatment guidelines from the National Heart, Lung and Blood Institute make it easier for parents to assess a child's condition. According to the guidelines, if a child is coughing or wheezing or has other asthma symptoms, uses rescue medications more than two days a week, has asthma-related nighttime awakenings more than twice a month, or has had two or more asthma attacks that required oral steroids in the last year, the asthma is not well controlled.

Such symptoms may arise because parents are uncertain about what environmental control measures to employ and how and when to use medications. "The most common reason why asthma is poorly controlled is underuse of prescribed medications or incorrect use of inhaler devices and spacers," says Elizabeth Jaffe, M.D., Ph.D., a pediatric allergy and immunology specialist at Timberlane Allergy and Asthma Associates in South Burlington, VT.

Managing Medications

"The goal is for your child to have zero symptoms, and that's possible for a significant number of kids," explains Paul V. Williams, M.D., a clinical professor of pediatrics at the University of Washington School of Medicine and a doctor with the Northwest Asthma & Allergy Center in Seattle. To that end, there are two basic types of asthma medicine: those that quell symptoms quickly and those used for long-term control.

Fast-acting (rescue) medications such as albuterol are short-acting bronchodilators. They are used to treat acute symptoms by relaxing the smooth muscle in the airways. However, they don't prevent a future episode. "I like to call rescue medication 'quick-relief,' because otherwise people think they should have their child use it only in an emergency," Dr. Williams says. "In fact, they should have the child use it whenever he or she has symptoms."

Children who have intermittent asthma—those who are symptom-free for long periods between attacks—can use rescue medications on an as-needed basis as their only therapy, according to Dr. Zeffren.

Long-term (controller) medications are used to prevent symptoms of asthma from occurring in the first place, in part by reducing inflammation in the airways. For children with persistent asthma, inhaled corticosteroids (ICS) are the long-term treatment of choice. Most experts say parents can feel comfortable giving a child inhaled steroids. "If there’s any long-term effect, it's small," says Dr. Williams.

For severe asthma, kids of all ages are often given a combination of an ICS and a long-acting beta agonist (such as salmeterol or formoterol) or a leukotriene-receptor antagonist (such as montelukast). This combination is also an option for kids 5 to 11 with moderate asthma.

Other long-term control medications include cromolyn sodium and immunomodulators (such as omalizumab, for kids 12 and older who have allergic asthma that is not well-controlled). Depending on whether a child's persistent asthma is mild, moderate or severe, one control medication may work well, or multiple medicines may be needed.

If a child's asthma is well controlled for three months, treatment guidelines suggest doctors consider scaling back the therapy (called a step-down approach). If the current therapy isn't controlling a child's asthma after two to six weeks, it's either time to adjust it upward (the step-up protocol) or to consider that other conditions, such as sinusitis, gastroesophageal reflux disease (GERD) or obstructive sleep apnea, may be aggravating the situation. Ultimately, the goal is to use the fewest medications at the lowest possible dose to gain and maintain asthma control, says Dr. Zeffren.

Med Smarts

Here are three errors that are commonly made when using asthma medications:

  1. The mistake: Stopping or cutting back on a controller medication once asthma is controlled.
    The concern: A child's symptoms may worsen, leading to emergency room visits, hospitalization and the need for more aggressive therapies.
    The fix: Stick with the regimen prescribed by your doctor until your child's next visit (every three to six months), then discuss the possibility of lowering the dose or altering the medication protocol.
  2. The mistake: Increasing reliance on rescue medication to treat symptoms, or using it daily.
    The concern: If your child needs to use rescue medication regularly, it means the asthma isn't responding adequately; controller medications are likely needed to relieve airway inflammation.
    The fix: Dr. Williams says if your child is using a rescue medication every four hours, talk to the doctor immediately about the situation. Whenever rescue medication is used more than usual, talk to the doctor to determine what can be done.
  3. The mistake: Not properly coordinating inhaler activation and inhalation of medicine.
    The concern: Your child may not be getting an adequate amount of medicine into the airways. (As of January 1, 2009, albuterol inhalers have had their chlorofluorocarbon propellant replaced by hydrofluoroalkane; the new inhalers produce a less forceful mist, so you and your child may have to tinker with the timing of inhalations.)
    The fix: To help younger children get an adequate dose of an inhaled medication into the airways, use a spacer with a mask, a holding chamber with a mouthpiece, or a nebulizer.

Publication Review By: Raymond Slavin, M.D.; Derek Johnson, M.D. for MDminute™

Published: 30 Sep 2009

Last Modified: 31 May 2011