Step 2 therapy for children 1 to 5 years
Some children aged 1 to 5 years who wheeze benefit from Step 2 therapy with a preventer, to reduce the frequency and severity of symptoms and maintain a normal quality of life. Children who start preventer therapy should still be prescribed salbutamol for relief of acute symptoms.
Trial a regular preventer in children aged 1 to 5 years:
- who have symptoms requiring salbutamol occurring at least once a week
- who have had two or more moderate wheezing episodes (requiring emergency-department care or oral corticosteroids) in the last year
- following any severe wheezing episodes (requiring hospital admission).
Consider a preventer for children with symptoms that are infrequent (eg every 4 to 6 weeks) but severe (eg post-tussive vomiting, nocturnal cough) or occur between viral respiratory tract infections.
An inhaled corticosteroid (ICS) is the preferred preventer for most children. Fluticasone propionate is the only ICS suitable for children 1 to 5 years. If a preventer is indicated, start therapy with a low dose of fluticasone propionate. Use:
fluticasone propionate 50 to 100 micrograms by inhalation via pMDI with spacer (and mask if required), twice daily. asthma, Step 2 therapy (child 1 to 5 years) fluticasone propionate
Explain that ICS therapy needs to be used every day to be effective, and does not relieve acute symptoms. See also Inhaled corticosteroids for asthma in children for general considerations about using ICS in children.
Educate parents and carers about how to use the inhaler, including advice about using a spacer (recommended for all children) and a mask (if required). See here for information about using masks and spacers, and Summary of inhalational drug delivery devices for links to instructional videos and patient handouts for pMDIs.
Montelukast can be considered instead of an ICS in children unable to use a pMDI (with spacer and mask), or if the child’s parents or carers remain concerned about using an ICS after an informed discussion. Montelukast may also be beneficial in children with coexisting allergic rhinitis, or exercise-induced bronchoconstriction. Use:
montelukast 4 mg orally, once daily1. asthma, Step 2 therapy (child 1 to 5 years) montelukast
Explain that montelukast needs to be used every day to be effective, and does not relieve acute symptoms.
Assess symptom control 4 to 6 weeks after starting fluticasone propionate or montelukast. See Assessment of asthma control in children for details about review, and definitions of good, partial and poor control.
If symptoms are well controlled with Step 2 therapy, continue therapy and review the child again after 3 months. Therapy may be able to be stepped down if control remains good—see Stepping down therapy.
If the child has partial or poor control on Step 2 therapy, review adherence and, if using fluticasone propionate, review inhaler technique and check equipment (inhaler, spacer, mask) for breakage or blockage. Before escalating to Step 3 therapy, also assess for symptoms and signs that indicate an alternative diagnosis or a comorbidity (eg rhinitis), and ensure exposure to triggers are minimised. Poor response to therapy (particularly to correctly used ICS) could indicate that the provisional diagnosis of asthma is incorrect. Very few children aged 1 to 5 years require Step 3 therapy to achieve good control.
If the child is taking montelukast, switch therapy to low-dose fluticasone propionate, if possible, rather than escalating to Step 3 therapy.