Step 2 therapy for children 6 years and older

Some children with asthma benefit from Step 2 therapy with a preventer, to reduce the risk of exacerbations, and minimise the interference of asthma in the child’s life. The need for preventer therapy depends on the frequency and severity of symptoms. Trial a regular preventer in children aged 6 years and older:

  • who have persistent asthma (daytime symptoms at least once per week, night-time symptoms at least twice per month, or symptoms that restrict activity or sleep)
  • who always require SABA therapy before exercise
  • who have had two or more moderate exacerbations (requiring emergency-department care or oral corticosteroids) in the last year, and also have symptoms at least every 6 weeks
  • following any severe exacerbation (requiring hospital admission including ICU admission).

Also consider a preventer for children who have:

  • frequent intermittent asthma (symptoms at least every 6 weeks)
  • had two or more moderate exacerbations (requiring emergency-department care or oral corticosteroids) in the last year, but usually have infrequent intermittent asthma (symptoms less than every 6 weeks).

Children who start preventer therapy must be prescribed a SABA for relief of acute symptoms.

An inhaled corticosteroid (ICS) is the preferred preventer for most children. For Step 2 therapy with regular low-dose ICS, with SABA reliever therapy, use:

a SABA as required (see Step 1 for dosage)

PLUS ONE OF THE FOLLOWING

1 fluticasone propionate 50 to 100 micrograms by inhalation via pMDI with spacer or via DPI, twice daily1 asthma, Step 2 therapy (child 6 years or older) fluticasone propionate

OR

1 ciclesonide 80 to 160 micrograms by inhalation via pMDI with spacer, once daily asthma, Step 2 therapy (child 6 years or older) ciclesonide

OR

1 budesonide 100 to 200 micrograms by inhalation via DPI, twice daily12 asthma, Step 2 therapy (child 6 years or older) budesonide

OR

1 beclometasone 50 to 100 micrograms by inhalation via pMDI with spacer, twice daily. asthma, Step 2 therapy (child 6 years or older) beclometasone

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 using a pMDI) and a mask (if required for children using a pMDI). 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 devices.

Montelukast can be considered instead of an ICS in children unable to use an inhaler (including a pMDI with spacer and mask), or if the 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 5 mg orally, once daily3. asthma, Step 2 therapy (child 6 years or older) montelukast

Explain that montelukast needs to be used every day to be effective, and does not relieve acute symptoms.

Assess symptom control (see Assessment of asthma control in children) 4 to 6 weeks after starting preventer therapy. 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 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 the child has partial or poor control on Step 2 therapy, review adherence and, if using ICS, 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 is minimised. Poor response to therapy (particularly to correctly used ICS) could indicate that the diagnosis of asthma is incorrect. Few children aged 6 years and older require Step 3 therapy to achieve good control.

If the child is taking montelukast, switch therapy to low-dose ICS therapy, if possible, rather than escalating to Step 3 therapy.

1 pMDI with spacer is usually the preferred option for all children. Older children (eg children older than 10 years) can use a DPI based on individual ability following device training. Return
2 In stable asthma, daily doses of budesonide up to 400 micrograms can be given once daily. Return
3 Neuropsychiatric adverse effects (eg behavioural changes, depression, suicidality) have been reported in all age groups taking montelukast. Adverse effects are generally mild and may be coincidental; however, symptoms may be serious and continue if treatment is not stopped. Advise patients, parents and carers to be alert for changes in behaviour and new psychiatric symptoms. Stop treatment if these effects occur. In some cases, symptoms may persist after stopping treatment; patients should be monitored and provided supportive care until symptoms resolve. See the Australian Therapeutic Goods Administration (TGA) safety alert for more information. Return