Step 3 therapy for children 1 to 5 years
Very few children aged 1 to 5 years require Step 3 therapy to control symptoms. Step 3 therapy can be considered in children who do not achieve good control with Step 2 therapy despite good adherence and inhaler technique, and after exclusion of alternative diagnoses.
Refer all children requiring Step 3 therapy to a paediatrician or paediatric respiratory physician. Step 3 therapy can be started while awaiting specialist review.
If Step 3 therapy is appropriate, use either:
- a high paediatric dose of fluticasone propionate—this is the preferred option in most children
- a low paediatric dose of fluticasone propionate plus montelukast—this may be more effective in children with coexisting allergic rhinitis, and may be used to reduce corticosteroid exposure.
If high-dose fluticasone propionate is preferred, use:
fluticasone propionate 125 micrograms by inhalation via pMDI with spacer (and mask if required), twice daily1. asthma, Step 3 therapy (child 1 to 5 years) fluticasone propionate
If low-dose fluticasone propionate plus montelukast is preferred, use:
fluticasone propionate 50 to 100 micrograms by inhalation via pMDI with spacer (and mask if required), twice daily fluticasone propionate
PLUS
montelukast 4 mg orally, once daily2. asthma, Step 3 therapy (child 1 to 5 years) montelukast
Explain that preventer 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 inhaled medication, including advice about using a spacer (recommended for all children) and a mask (if required). See Inhalational drug delivery devices for information about using masks and spacers, and Summary of inhalational drug delivery devices for links to instructional videos and patient handouts for pMDIs.
Assess symptom control after 4 to 6 weeks. See Assessment of asthma control in children for details about review, and definitions of good, partial and poor control.
If symptoms are well controlled, continue treatment 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 symptoms remain uncontrolled with Step 3 therapy, review the diagnosis and arrange referral (if not already arranged). See also Severe asthma in children for information on specialist treatments for asthma.