Managing mild and very mild asthma in preschoolers, children and adolescents

Children with very mild or mild asthma comprise 28% to 41% of the pediatric population with asthma. To assist pediatricians and primary healthcare providers in caring for these patients, the Canadian Paediatric Society has published a practice point document on the pharmacologic management of very mild or mild asthma in children older than one year.1 The contents are based on recommendations from the Canadian Thoracic Society’s 2021 asthma guideline update.2Asthma severity is defined by the level of treatment required to maintain asthma control and can fluctuate over time. Very mild asthma requires a “prn” short-acting beta-agonist (SABA) to maintain control. Mild asthma requires a low-dose inhaled corticosteroid (ICS), or leukotriene receptor antagonist (LTRA) plus a prn SABA, or prn budesonide/formoterol to maintain control. Severity can only be accurately determined when asthma is well controlled and factors such as adherence and correct inhaler technique have been taken into account. All individuals with asthma are at risk for asthma exacerbations, or even death if untreated, regardless of disease severity.1Asthma control is assessed by taking a careful history of symptoms and exacerbations, and by reviewing lung function in children who are able to do spirometry (typically those ≥ 6 years of age). Well-controlled asthma in preschoolers, children and adolescents is defined by the following criteria:Daytime symptoms: ≤ 2 days per week (Note: this is a decrease from previous guidelines, which stated < 4 times per week).Nighttime symptoms: < 1 night per week and mildPhysical activity: normalExacerbations: mild and infrequent (a mild exacerbation does not require a systemic corticosteroid, emergency department visit or hospitalization)Absence from work or school due to asthma: noneNeed for a reliever (SABA or budesonide/formoterol): ≤ 2 doses per weekForced expiratory volume in 1 second (FEV1) or peak expiratory flow (PEF): ≥ 90% of personal bestPEF diurnal variation: < 10%–15%.1 Read: Respiratory coinfections less common in older children with COVID-19TreatmentAsthma treatment requires providing asthma education (and a written asthma action plan), identifying asthma triggers, and discussing environmental modifications (when applicable).1Pharmacologic treatment options are based on age, risk for exacerbation and, in some cases, personal preference. Even patients with well-controlled asthma can still be at higher risk of exacerbation; therefore, exacerbation risk should be assessed to inform treatment recommendations.1 Young people considered at higher risk for exacerbation are those who: Have any history of a severe asthma exacerbation (i.e., requiring use of a systemic corticosteroid, or an emergency department visit or hospitalization)Have poorly controlled asthmaOveruse a SABA (i.e., > 2 SABA inhalers over a 1-year period), orCurrently smoke. Passive exposure to smoke and inhalation of other substances (e.g., vaping, cannabis) are also risk factors for asthma exacerbation.1 Individuals with very mild or mild asthma who are at higher risk of exacerbation should not be prescribed PRN SABA alone.1Read: Key clinical guidelines and statementsMild asthmaA daily ICS remains the first-line treatment for mild asthma. Mild asthma is better controlled with daily ICS and prn SABA than with prn SABA alone, including in preschoolers.1As a second-line option to daily ICS, a daily leukotriene receptor antagonist (LTRA) can be used for individuals of any age who cannot or will not use daily ICS. Neuropsychiatric side effects (e.g., irritability, aggressiveness, anxiety, sleep disturbance) are reported in up to 16% of children started on LTRAs.1 Adolescents (≥12 years of age) with mild asthma can use prn budesonide/formoterol as a therapeutic option instead of low-dose daily ICS plus prn SABA; prn budesonide/formoterol is preferred only for individuals with poor adherence to daily ICS despite substantial patient education and support.1Budesonide/formoterol is only available as a dry powder inhaler. Healthcare providers should ensure that children can use the device properly, as it requires inhaling consistently, deeply and forcefully to deliver the medication.1 Short courses of ICS for acute asthma symptoms (e.g., for 10–14 days) at the onset of an acute loss of asthma control is not recommended compared with prn SABA. Rather, daily ICS is recommended as the preferred strategy for most children with asthma because of consistent evidence for decreased exacerbations, better asthma control and improved lung function compared with prn SABA. Regular ICS use also results in more days with well-controlled asthma and less use of beta-agonists, when compared with intermittent ICS use for acute asthma symptoms.1Algorithm and ICS dosing table The practice point document includes an algorithm that summarizes the pharmacologic treatment of very mild and mild asthma in children. A table is also provided outlining inhaled corticosteroid dosing categories (low, medium and high) to manage asthma in children according to age group (1–5 years, 6–11 years and ≥ 12 years).1References1. Yang C, Zysman-Colman Z, Chétrit E, et al; Canadian Paediatric Society. The management of very mild and mild asthma in preschoolers, children, and adolescents. Posted online December 8, 2023. (accessed December 21, 2023).2. Yang CL, Hicks EA, Mitchell P, et al. Canadian Thoracic Society 2021 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Can J Respir Crit Care Sleep Med 2021;5(6):348-61. (accessed December 21, 2023).

Managing mild and very mild asthma in preschoolers, children and adolescents

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