A trial of the powder form of a B-agonist such as albuterol may be easier for a child to use than a metered dose inhaler. Use of an MDI with a spacer with face mask attachment may be particularly helpful in young patients, to ensure better delivery of aerosol medication. As with adult patients there is a greater chance of side effects (nervousness, tremor) in a child receiving oral or nebulized medication.



Children with mild persistent asthma should add an anti-inflammatory agent such as cromolyn or nedocromil to the B2-adrenergic agonist. Cromolyn is the preferred choice due to the absence of total body effects. It is approved for children aged five and older with insufficient data for younger patients. Cromolyn is available for nebulizer use, which may be more suitable for younger patients as well as an MDI. Nedocromil has been approved for children aged six and older and is only currently available as an MDI. A nebulizer preparation of nedocromil should be available shortly. Alternative agents include the anti-leukotriene montelukast and the inhaled corticosteroids.

The inhaled corticosteroids have been found to affect bone growth and adrenal function in children in dosages above 400 p.g per day but are considered safe up to this dosage. A DPI preparation of fluticasone (Flovent Rotadisk) has recently been approved for children four years of age and older. The side effects of using higher dosages of inhaled corticosteroids in children should be weighed against the effects of uncontrolled asthma. There is insufficient data on the use of the inhaled corticosteroids in children below the age of four.

Treatment Strategy: Moderate Childhood Asthma

Children with moderate persistent asthma experience daily symptoms and have more than two attacks each week. These patients require higher dosages of the inhaled corticosteroids and the addition of a long-acting B2-agonist such as salmeterol. The anti-leukotriene montelukast may also be used as an alternative anti-inflammatory agent.

Salmeterol

The long-acting B2-adrenergic agonist, salmeterol, may be used for the control of moderate persistent asthma in children aged five and older. The pediatric dosage is one to two inhalations every twelve hours. Children with primarily nocturnal symptoms may use one dose nightly.

Theophylline

Theophylline should be considered for use in the childhood asthmatic who is uncontrolled on the above therapy. Unfortunate side effects such as nervousness, however, limit its usefulness. Recent studies have raised the question of a learning disability that may be attributed to theophylline. Additional adverse effects are stomach upset and headache. As in adults, blood levels must be monitored to ensure an effective therapeutic level.

Anticholingergic Agents

The anticholinergic agent ipratropium bromide may be used in children aged twelve and older as a second or third-line agent. Since most childhood asthmatics are allergic, it is not likely that this agent would provide significant bronchodilatation. It is available in a nebulizer form as well as an MDI.