Asthma Medication for Children

There are 2 main groups of asthma medication in children:

• reliever or relief medication - for relief of an acute attack of asthma.Generally, reliever medication is only taken during an acute attack of asthma.
• preventer medication - to reduce the frequency of attacks. Generally, preventer medication is taken daily regardless of whether there are any symptoms or not.

Within each group, there are a number of different agents that may be used. The types of drugs that are used include:

• bronchodilators - drugs that open up the airways. Short-acting bronchodilators are used as relievers or relief asthma medication
. There are also long-acting bronchodilators that are sometimes used as preventers.
• anti-inflammatory agents - these reduce the inflammation in the airways. It is the inflammation that causes the airways to go into spasm and become narrow. These agents are used to try and reduce the frequency of acute attacks and so are preventers. Some anti-inflammatory agents are also used in an acute attack (so as a reliever) - for example, oral steroids.

This page answers the following questions on asthma medication:

• Will my child need a reliever and a preventer?
• How will I know if my child needs a preventer?
• What are the reliever medications?
• What is the dose of the reliever medication?
• What if my child has a severe asthma attack?
• Is a nebulizer better than a spacer?
• How do I use a spacer with asthma inhalers?
• How do I wash the spacer?
• What if I don't have a spacer?
• What is the treatment of an acute asthma attack?
• Are steroids dangerous in asthma?
• What preventer medications are available?
• Do preventers cause side effects?
• Are there other treatments other than medication?
• What is an Asthma Action Plan?

Infant using asthma spacer

Will my child need a reliever and a preventer asthma medication?

Not necessarily. Children with asthma will require a reliever for when they get symptoms.

Some children only get the occasional attack (this is classified as mild intermittent or mild episodic asthma). They will only need reliever medication when they get an attack and a preventer will not be necessary.

Some children will have more persistent symptoms and will require a preventer to try and reduce the attacks and symptoms. The aim is to have your child as symptom-free as possible so asthma doesn't interfere with her life.

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How will I know if my child needs preventer asthma medication?

Your doctor will be able to help you decide depending on how your child's asthma is classified - so is it:

• mild intermittent (mild episodic) - occasional attacks and symptoms less than twice a week
• mild persistent - symptoms more than twice a week but less than daily
• moderate persistent - symptoms daily
• severe persistent - severe symptoms daily and frequent severe attacks

If your child has asthma that is persistent, so frequent symptoms or attacks, then she will require a preventer.
I use the following to decide if a preventer is necessary:

• are there frequent attacks of asthma - is she needing frequent courses of steroids?
• is your child coughing at night even in between attacks of asthma?
• is your child getting wheezy or coughing with exercise, even when "well"?
• is your child missing school or nursery because of asthma symptoms?
• is your child requiring a reliever more than 4 times a week when she is "well"

If the answer to the above is "YES", then I would consider a preventer being added into the asthma management plan.

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What are reliever asthma medication options?

The first thing for treatment in an acute asthmatic attack is a bronchodilator, an asthma medication that will open up the narrow airways and make it easier to breath.

The most frequently used bronchodilators used are

• Salbutamol / Albuterol (in North America)
• Ipratropium bromide - used in conjunction with Salbutamol / Albuterol in severe attacks
• Terbutaline

These drugs are delivered by an inhaler and so are directed at the lungs where they work. Young children need a spacer device to get the drug delivered to the lungs appropriately. The inhaler is put in one end of the spacer and the child breathes in and out through the other end and the drug is then administered through the spacer. Younger children like the photo above need a mask on the end of the spacer as well. Older children can just put their lips around the mouthpiece. See photos

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What is the dose of reliever asthma medication?

Your doctor will probably give you an asthma management plan so you should follow that if you have one.

I tend to use the following dose regime for reliever asthma medication as it's easy to remember - just remember the number 4:

• 4 puffs of the relief inhaler, four times a day for four days starting at the beginning of an attack.
• if the attack is severe, you can give 6- 10 puffs up to every 4 hours if necessary but if your child needs doses more frequently than every 4 hours, seek medical attention
• there should be about 4 breaths that your child takes between each puff of the inhaler

There is nothing magic about 4 but it is a safe regime and it's easy to remember.

We give children up to 10 puffs at one time in hospital and you can do this at home as well, but if your child is not responding or is needing treatment more than every 4 hours, I think it is safest to seek medical attention at that point rather than keep trying at home unless you have a plan that say otherwise from your doctor.

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What if my child has a severe attack?

If your child has a severe asthma attack, so if she is really struggling for breath or she can't talk, you are best to call an ambulance. While you are waiting, give your child 10 puffs of the relief inhaler via the spacer. You can repeat this process if necessary until the ambulance arrives. The ambulance will be able to give your child oxygen if necessary.

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Toddler asthma spacer

Is a nebulizer better than a spacer for relief asthma medication?

No. There have been a number of studies that have shown that spacers are as effective as nebulizers for getting control of asthma symptoms.

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How do I use the spacer?

Spacer with mask	Spacer no mask

• The first time you use the spacer, you will need to prime it - so that means putting the inhaler in one end and pushing the inhaler to deliver 10 puffs (so 10 pumps of the inhaler). This coats the walls of the inhaler and reduces static that would otherwise interfere with doses.
• Once the spacer is primed, you can use it during attacks (with the reliever) or with the preventer. You can use the same spacer for both reliever and preventer drugs.
• Before you put the inhaler in the spacer, shake it - you will need to shake the inhaler after every 2 puffs
• Put the inhaler in the end of the spacer and get your child to breathe in and out at the other end - infants may need a mask attached at their end. See photo
• Push the inhaler and deliver one puff. Wait while your child takes 4 or 5 breaths in and out and then give another puff. Wait another 4 or 5 breaths before giving further puffs and remember to shake the inhaler after every second puff.

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How do I wash the spacer?

The spacer should be washed in hot soapy water and then left to drip dry. Do not dry with a tea towel as this will interfere with the way the drug is delivered.

You should wash the spacer once a week.

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What can I do if I don't have an asthma spacer?

You can use a plastic 500 ml drink bottle. Cut a hole in the base of the bottle for the spacer and your child can breathe through the top.

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What is the treatment of an acute asthma attack?

• The first line asthma medication for an acute attack is a bronchodilator, such as Salbutamol / Albuterol, given via a spacer.
• Children will also often need an anti-inflammatory agent as well. Most commonly, steroids are given. They can be given by mouth, such as oral prednisone or oral prednisolone, or they can be given by an inhaler via a spacer, such as inhaled fluticasone or inhaled budesonide.

  I use oral prednisolone (prednisone) and give it for only a few days (2 - 4 days) in a row. I give it until the symptoms are clearly resolving.

• If the above measures are not enough, children will need to be in hospital where they can have oxygen and other medications which may need to be given intravenously

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Are steroids given in an acute asthma attack dangerous?

No. The steroids given are like the natural steroids the body produces in stress and they are very useful at reducing airway inflammation and asthma symptoms. They are not the same steroids that you hear about being abused by athletes.

I would use oral steroids in all acute asthma attacks that are more than mild (so any that don't respond to the initial 4 puffs, 4 times a day for 4 days regime).

As long as the course doesn't last more than a week or so, there is no need to taper the dose. Most children need only 3 or 4 days of oral steroids so are given the same dose for the whole course.

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What preventer asthma medications are available?

There are accepted guidelines for adding in preventer asthma medication when it is necessary. There is a step-wise approach that means one preventer will be added, the dose optimized and then another agent will only be added or substituted if there has been an inadequate response.

The agents used as preventers are:

• inhaled corticosteroids (steroids) - such as fluticasone, budesonide, beclomethasone, triamcinolone. These have shown the most effectiveness as preventers and have an anti-inflammatory action
• long-acting bronchodilators - such as salmeterol. These are often added onto inhaled steroids but children on these medications should be under specialist monitoring as they can then have severe and life-threatening asthma attacks
• Leukotriene receptor antagonists - such as Montelukast. This also works by reducing inflammation of the airways. They are not as effective preventers as inhaled corticosteroids
• Cromolyn and Nedocromil - these are also anti-inflammatory agents. They are sometimes used as first-line preventer asthma medication in mild persistent asthma, particularly if the trigger is cold air or exercise
• Theophylline - is given orally. It has a narrow range of safety so isn't used so much anymore as inhaled steroids are so effective in most cases

The key to preventer agents is that they are given every day not just when there are symptoms.

Once your child has been free of symptoms for 3 - 6 months, you could try and stop the preventer. If symptoms return, it is an indication that your child continues to need the preventer.

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Do preventer steroids cause side effects?

In the correct dose, there are usually no side effects from inhaled steroids used as preventer asthma medication.

The main concern has been about growth and whether inhaled steroids will reduce final adult height. Studies have not shown any reduction in adult height in children with asthma who were treated long-term with inhaled steroids at moderate doses.

Your child may need to be monitored more closely if she required more than 400 micrograms per day of Beclomethasone or Budesonide, or more than 200 micrograms per day of Fluticasone.

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Are there other treatments for asthma other than medication?

Buteyko Breathing Technique has been shown in studies to improve asthma symptoms and reduce use of asthma medication. It is recommended that it be used in conjunction with asthma medication rather than instead of medication.

Click here to visit a site where you can download a free guide for using Buteyko for childhood asthma.

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What is an Asthma Action Plan?

Asthma Action Plans have been shown to improve asthma management in children. They outline what asthma medication to use and when for your child.

Ask your doctor to give you one. Your doctor can visit the Royal Children's Hospital, Melbourne website and complete a form which will generate an action plan for your child.

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References

• Keeley D, McKean M. Asthma and other wheezing disorders in childhood. Clinical Evidence. BMJ group. 2007.
• Milgrom H. Childhood Asthma: Breakthroughs and Challenges. Chapter in "Advances in Pediatrics" Vol 53. Mosby 2006 ISBN 1 4160 3324 6
• Allen D. Effects of Inhaled Steroids on Growth, Bone Metabolism and Adrenal Function. Chapter in "Advances in Pediatrics" Vol 53. Mosby 2006 ISBN 1 4160 3324 6
• Zar et al. Randomised controlled trial of the efficacy of a metered dose inhaler with bottle spacer for bronchodilator treatment in acute lower airway obstruction. Arch Dis Child. Feb 2007; 92 (2):142 - 146
• Bowler SD, Green A, Mitchell CA. Buteyko breathing techniques in asthma: a blinded randomised controlled trial. Med J Aust. 1998 Dec 7-21;169(11-12):575-8.
• Cooper S, Oborne J, Newton S, Harrison V, Thompson Coon J, Lewis S, Tattersfield A. Effect of two breathing exercises (Buteyko and pranayama) in asthma: a randomised controlled trial. Thorax. 2003 Aug;58(8):674-9.

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Last reviewed 28 September 2011

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