Diagnosis

1. Medical history and physical examination
2. Assessment of symptoms
   • Exclusion of alternative diagnoses
   • Risk factor evaluation
   • Measurement of peak expiratory flow (PEF)
   • Peak-flow monitoring
   • Measurement of forced expiratory volume in one second (FEV₁)
   • Reversibility testing (short-acting bronchodilator) of airflow obstruction
   • Trials of controller medications
3. Classification of asthma
   • Intermittent
   • Persistent
4. Ongoing evaluation of asthma control
   • Medical history
   • Physical examination
   • Spirometry
   • Peak-flow monitoring

Management

1. First-line control
   • Inhaled corticosteroids
   • Leukotriene receptor antagonists
   • Nedocromil sodium
2. Additional controlled medications, dosing, and adverse events
   • Inhaled corticosteroids (increased dose)
   • Leukotriene receptor antagonist (in addition to inhaled corticosteroids)
   • Long-acting beta-agonist
3. Self-management and education
   • Patient education
   • Provider education
   • Written action plan

Treatment

Recommendations are identified as either "evidence-based (A-D, I)" or "consensus-based." For definitions of the levels of recommendations see the end of the "Major Recommendations" field.

Diagnosis of Asthma in Children and Adolescents

1. Consider the diagnosis of asthma in any child according to the following criteria:
   • Episodic symptoms of airflow obstruction, as noted by:
     • History of recurrent wheezing, cough, shortness of breath, or chest tightness
     • Physical examinations that document recurrent episodes of coughing or wheezing
   • Airflow obstruction that is at least partially reversible, as demonstrated by:
     • Wheezing on physical examination that improves with the use of a bronchodilator
     • An improvement of 12% in forced expiratory volume in 1 second (FEV₁) or 20% in peak expiratory flow (PEF) after inhalation of a short-acting bronchodilator
   • Exclusion of alternative diagnoses:
     • Gastroesophageal reflux disease
     • Obstructive sleep apnea
     • Recurrent or chronic sinusitis
     • Foreign body aspiration
     • Vocal cord dysfunction
     • Panic attack, hyperventilation, tracheoesophageal fistula, vascular rings, or other pulmonary disease (e.g., cystic fibrosis)

   (Note: This should be considered a partial, not a comprehensive list.)

Consensus-based*

2. In addition to the above definition of asthma, the following are options to help establish the diagnosis of asthma (Note: No one tool is considered diagnostic.):
   • Risk factor evaluation (such as a history of asthma in the parents, cigarette smoke exposure, diagnosis of eczema, allergic rhinitis, or positive allergy skin or blood tests)
   • Peak-flow monitoring over one to two weeks that shows > 20% diurnal variation
   • Trials of controller medication (e.g., Qvar®, Asmanex®, Flovent®, or Pulmicort) for approximately one to three months followed by a clinical reassessment, including peak-flow or spirometry measurement

Consensus-based*

3. For asthma patients who have severe or frequent symptoms or when diagnosis is in doubt, consider referral to an asthma specialist for further evaluation.

Consensus-based*

*There is insufficient evidence to recommend for or against the following methods, in isolation, for establishing a diagnosis of asthma in children or adolescents: assessment of asthma symptoms, risk factor evaluation, physical examination, spirometry, trials of controller medication, response to albuterol, peak-flow meters, or histamine/methacholine/exercise challenge. Evidence-based: I

Initial Classification of Asthma

1. Symptom assessment (while off controller medication) and (if indicated) lung function testing are recommended for classifying asthma as intermittent or persistent in children and adolescents, as defined by National Heart Lung and Blood Institute (NHLBI).

   Intermittent:

   • Symptoms occurring no more than twice a week, asymptomatic with normal PEF between exacerbations, and brief exacerbations (i.e., a few hours to a few days) with varying intensity; AND
   • Nighttime symptoms no more than twice a month; AND
   • FEV₁ or PEF > 80% of predicted, PEF variability < 20%

   Persistent:

   • Symptoms occurring more than twice a week, with exacerbations severe enough to affect daily activity; OR
   • Nighttime symptoms more than twice a month; OR
   • FEV₁ or PEF < 80% of predicted, PEF variability 20% to 30%

Consensus-based*

2. In infants and young children 5 years old or younger, where lung function cannot be performed, assessments of additional symptoms and laboratory tests are recommended for classifying asthma as intermittent or persistent, as noted by NHLBI
   • Consider a child to be at risk for persistent asthma who has had more than three episodes of wheezing in the past year that lasted more than a day and affected sleep; AND
   • Has had either:
     • A physician diagnosis of atopic dermatitis or parental history of asthma, OR
     • At least two of the following conditions:
       1. Allergist-diagnosed allergic rhinitis
       2. Greater than 4% eosinophils on complete blood count
       3. Wheezing apart from colds

Consensus-based*

*There is insufficient evidence to recommend for or against the use of symptom assessment or lung function testing for classifying asthma as intermittent or persistent in children or adolescents. Evidence-based: I

Ongoing Evaluation of Asthma Control

1. The following components are recommended for clinical evaluations of asthma control in children and adolescents:
   • A recent medical history covering topics such as waking at night with cough or wheeze, the ability to exercise, attendance at school/preschool, and beta-agonist use (the Childhood Asthma Control Test (ACT) for children aged 4 to 11 and the ACT for children aged 12 to 18 are options)
   • A physical examination, including weight and height percentile information, evaluations of wheezing, auscultation and exhalation, and chest deformity

   Use of spirometry to assess response to albuterol before and after use of bronchodilators is an option in clinical evaluation of asthma control in children and adolescents.

Consensus-based*

2. Clinicians are advised to instruct child and adolescent patients to keep a symptom diary (assessing frequency of cough or wheezing, nocturnal asthma symptoms, and inhibition of daily activities of living) in order to evaluate asthma control.

Consensus-based*

3. When peak-flow monitoring is used to measure control, asthma should be considered poorly controlled when peak flows show > 20% diurnal (a.m. vs. p.m.) variability. Assessment of control using peak-flow information should include a check of patient peak-flow technique and effort.

Consensus-based*

4. The use of peak-flow monitoring in the initial evaluation of asthma control is an option for children and adolescents aged 6 years and older.

Evidence-based: C

5. Ongoing or long-term peak-flow monitoring is an option for select patients with poorly controlled disease or in patients who are poor perceivers of their symptoms.

Consensus-based*

*There is insufficient evidence to recommend for or against the use of the following methods of evaluating asthma control in children and adolescents: spirometry, symptom or beta-agonist use assessments, (e.g., the ACT), nitric oxide evaluation, or peripheral blood eosinophil evaluation. Evidence-based: I

Stepwise Medical Management

First-Line Controller Medications, Dosing, and Adverse Effects

1. Inhaled corticosteroids are strongly recommended as first-line controller medication for children and adolescents with persistent asthma.*

Evidence-based: A

2. When initiating therapy, a low dose of inhaled corticosteroids twice a day is recommended.^a For patients with severe asthma and/or poor control, an initial medium dose and adjustment to the lowest effective dose is an option.

Consensus-based^b

3. For children who cannot tolerate or who decline inhaled corticosteroids or those for whom the medication is contraindicated, leukotriene receptor antagonists or nedocromil sodium are recommended as alternative first-line options.^c

Evidence-based: B

4. Long-acting beta-agonists and cromolyn sodium are not recommended as first-line treatment for children and adolescents with persistent asthma.^c

Evidence-based: D

*There is insufficient evidence to determine the efficacy of triamcinolone, flunisolide, or mometasone in children and adolescents; however, a class effect is assumed.

^aSee Table 1 in Appendix A for Estimated Daily Dosages of Inhaled Corticosteroids on page 205 in the original guideline document.
Mometasone is indicated once per day.

^bThere is insufficient evidence to recommend the initial dose (high, medium, or low) and frequency of dosing for children and adolescents initiating inhaled corticosteroids. Evidence-based: I

^cSee Table 2 in Appendix A for Usual Dosages for Long-Term Control Medications on page 206 in the original guideline document.

Additional Controller Medications, Dosing, and Adverse Effects*

1. For children whose asthma is not controlled by a long-term controller medication, a referral to an asthma specialist for further evaluation and education is recommended.

Consensus-based

2. In children older than 4 years whose asthma is not controlled with the proper use and administration of inhaled corticosteroids, increasing the dose is recommended.**

Evidence-based: B

3. In children whose asthma is not controlled with the proper use and administration of inhaled corticosteroids alone, adding a leukotriene receptor antagonist is an option.

Evidence-based: C

4. In children older than 4 years whose asthma is not controlled with the proper use and administration of inhaled corticosteroids alone, adding a long-acting beta-agonist is an option.

Consensus-based

5. The addition of cromolyn for children and adolescents whose asthma is uncontrolled by inhaled corticosteroids is not recommended.

Evidence-based: D

*There is insufficient evidence to recommend for or against the addition of the following medications for children and adolescents whose asthma is not controlled by inhaled corticosteroids: long-acting beta-agonists (salmeterol, formoterol), nedocromil, theophylline, or anti-IgE immunotherapy. Evidence-based: I

^**See Table 1 in Appendix A for Estimated Daily Dosages of Inhaled Corticosteroids for appropriate low, medium, and high doses on page 205 in the original guideline document.

Asthma Self-Management and Education

1. Ongoing patient education, including the components of clinician follow-up, monitoring, reinforcement, and adherence strategies, is recommended for improving asthma control in children and adolescents.

Consensus-based*

2. Continuing education for providers is recommended for improving asthma control in children and adolescents.

Evidence-based: B

3. Written action plans (peak flow and/or symptom-based) as part of an overall effort to educate patients in self-management are recommended, especially for patients whose asthma is not controlled by long-term controller medication and for patients with a history of severe exacerbations. The goal of the action plan is to provide information on the timing and method of increasing treatment, the duration of treatment, and when and how to seek medical help.

Consensus-based*

*There is insufficient evidence to recommend for or against extended patient education, psychosocial services, written action plans, adherence strategies, care management, case management, or the use of clinician monitoring and reinforcement for improving asthma control in children and adolescents with asthma.

Treatment of Exercise-Induced Asthma*

1. For children and adolescents with exercise-induced asthma, a short-acting beta-agonist (albuterol, two puffs) 5 to 15 minutes prior to exercise is recommended as initial therapy.

Evidence-based: B

2. For patients for whom pretreatment with an inhaled short-acting beta-agonist does not adequately prevent symptoms, first check inhaler technique, and then check for underlying persistent asthma. If inhaler technique is appropriate, consider a diagnosis of persistent asthma and start a trial of treatment with low-dose maintenance inhaled corticosteroid for 30 days.

Consensus-based

3. For children and adolescents with exercise-induced asthma, leukotriene receptor antagonists (montelukast, 5 mg once a day) are an option.

Evidence-based: C

4. For those patients whose exercise-induced asthma does not respond to short-acting beta-agonists, inhaled corticosteroids, or leukotriene receptor antagonists, a referral to an asthma specialist is recommended.

Consensus-based

*There is insufficient evidence for or against a recommendation of long-acting beta-agonists, loratadine, vitamin C, or omega-3 or -6 supplements for the treatment of exercise-induced asthma in pediatric patients. Evidence-based: I

Preventive Treatment of Acute Asthma Exacerbations Secondary to Viral Respiratory Tract Infections

1. Leukotriene receptor antagonists are an option for the preventive treatment of recurrent asthma exacerbations secondary to viral respiratory tract infections in children aged 5 years or younger who do not have evidence of persistent asthma.

Evidence-based: C

2. When leukotriene receptor antagonists are considered for the preventive treatment of recurrent asthma exacerbations secondary to viral respiratory tract infections in children aged five years or younger, who do not have evidence of persistent asthma, referral to an asthma specialist should be considered.

Consensus-based

3. There is insufficient evidence to recommend for or against the use of leukotriene receptor antagonists for the preventive treatment of acute asthma exacerbations secondary to viral respiratory tract infections in children and adolescents aged 6 years or older who do not have evidence of persistent asthma.

Evidence-based: I

4. There is insufficient evidence, due to conflicting results, to recommend for or against the use of inhaled corticosteroids for the preventive treatment of acute asthma exacerbations secondary to viral respiratory tract infections in children or adolescents who do not have evidence of persistent asthma.

Evidence-based: I

Treatment of Acute Asthma Exacerbations in a Clinical Setting

Mild to Moderate Exacerbations (PEF > 50% and/or oxygen saturation > 92% on room air)

1. For infants aged 2 years or younger presenting in the outpatient clinic, urgent care setting, or emergency department (ED) with mild to moderate exacerbations of asthma, albuterol is an option for the initial treatment of acute asthma.

Evidence-based: C

2. For children and adolescents in the outpatient clinic, urgent care setting, or ED, albuterol is recommended for the initial treatment of mild to moderate acute exacerbations of asthma, administered either by a metered-dose inhaler with spacer (with or without mask) under supervision, or by a hand-held nebulizer.

Evidence-based: B

3. Two to six puffs of albuterol via metered-dose inhaler with spacer or 0.15 mg/kg (2.5 mg minimum dose, 5 mg maximum dose) via hand-held nebulizer every 20 minutes for up to three doses is recommended.

Consensus-based*

*There is insufficient evidence to recommend for or against the use of metered-dose inhaler with spacer vs. hand-held nebulizer, levalbuterol vs. racemic albuterol, or high-dose vs. low-dose albuterol for the treatment of acute exacerbations. Evidence-based: I

Severe Exacerbations (PEF < 50% and/or oxygen saturation < 92% on room air) or Exacerbations Refractory to First-Line Treatment*

1. Nebulized ipratropium bromide and short-acting beta-agonists, every 20 minutes for up to three treatments, are recommended for the treatment of children (250 mcg/dose) and adolescents (500 mcg/dose) with severe exacerbations in the outpatient clinic, urgent care setting, or ED.**

Evidence-based: B

2. Supplemental oxygen (by nasal cannula or mask, whichever is better tolerated) to maintain an oxygen saturation > 92% is recommended during the delivery of short-acting beta-agonists and anticholinergics in patients with severe exacerbations.

   Monitor oxygen until a clear response to bronchodilator therapy has occurred.

Consensus-based

3. For children and adolescents in the outpatient clinic, urgent care setting, or ED with severe exacerbations of asthma, the early addition of either oral or parenteral systemic corticosteroids to short-acting beta-agonist therapy is strongly recommended.

Evidence-based: A***

4. A single dose of either oral or parenteral prednisone equivalent (1 to 2 mg/kg, up to 60 mg) is recommended.

Consensus-based

5. For patients who continue to be hypoxic after guideline-recommended treatment options and/or who require treatment more frequently than every two hours, hospital admission should be considered.

Consensus-based

*There is insufficient evidence for or against the addition of inhaled corticosteroids, leukotriene receptor antagonists, or long-acting beta-agonists to albuterol for children and adolescents presenting with severe exacerbations in the clinical setting. Evidence-based: I

**See the rationale for Recommendation 8A on page 161 in the original guideline document for the appropriate dose of short-acting beta-agonists.

***There is insufficient evidence to determine the difference between oral and parenteral corticosteroids, or high-dose and oral corticosteroids for the treatment of severe acute exacerbations or exacerbations refractory to first-line treatment. Evidence-based: I

Exacerbations Refractory to First- and Second-Line Treatments

1. For patients who are refractory to first- and second-line treatments, intravenous magnesium sulfate (25 to 40 mg/kg as a single dose over 20 minutes, maximum up to 2 g) is an option for children and adolescents treated for acute asthma in a hospital setting. It is recommended that patients be hospitalized for at least 24 hours.

Consensus-based*

*There is insufficient evidence to recommend for or against the use of intravenous or inhaled magnesium sulfate for children and adolescents refractory to first- and second line treatments for acute asthma in a clinical setting. Evidence-based: I

Discharge After Treatment of Acute Exacerbation

1. Discharge planning including a written action plan with clear instructions regarding beta-agonist use and follow-up is recommended. Parents should be instructed to return the patient urgently for further assessment and medical care if symptoms are not controlled by short-acting beta-agonists administered every three to four hours.

Consensus-based*

Quick Reference Guides/Physician Guides

The following is available:

• Kaiser Permanente Care Management Institute. Pediatric asthma clinical practice guidelines. Oakland (CA): Kaiser Permanente Care Management Institute; 2006 Aug. 13 p.

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.