Asthma is the most prevalent chronic disease in children.1 In the United States, asthma affects approximately 1.4 million children younger than 5 years2 and causes frequent activity limitations3 and hospitalizations.1,4 Unfortunately, a substantial number of children in this age-group have suboptimal asthma control, demonstrated by the higher rates of emergency department (ED) visits and hospitalizations in preschool-aged children than in older children.4
In the United States, mothers of children aged 1 to 5 years with persistent weekly asthma-like symptoms (ie, cough, wheeze, breathlessness) have reported that 22% of the children had an ED visit and 11% had been hospitalized within the past 6 months.5 In 2007, approximately 851,000 children younger than 5 years had an asthma attack in the past year, which represents 61% of the children with asthma in this agegroup. 2 These findings suggest that the treatment goals of asthma are not currently being met in preschoolaged children.
The goal of asthma therapy, detailed in the 2007 National Heart, Lung, and Blood Institute and National Asthma Education and Prevention Program's Expert Panel Report 3 (EPR-3),6 is to control asthma by reducing both the impairment and risk domains. Impairment addresses the daily impact of asthma on traditional clinical indices and quality of life. Risk refers to the negative consequences of the disease or pharmacotherapy.
Impairment is reduced by preventing chronic and troublesome symptoms, minimizing short-acting β2-adrenergic agonist (SABA) use to 2 or fewer days a week, maintaining near-normal pulmonary function, maintaining normal activity levels, and meeting patients' and families' expectation of and satisfaction with asthma care. Risk is reduced by preventing recurrent exacerbations of asthma and minimizing the need for ED visits or hospitalizations, preventing reduced lung growth, and providing optimal pharmacotherapy with minimal or no adverse events. Both domains may respond differently to treatment. Treatments are selected and adjusted on the basis of the patient's level of asthma control, which is determined by assessments made by the health care provider (HCP) and caregiver.
This review provides an overview on how to assess and achieve asthma control in children younger than 5 years and presents answers based on current asthma guidelines to the following questions that arise during clinic visits:
- Is the diagnosis asthma?
- Can a child outgrow asthma?
- How severe is the child's asthma?
- What are the current recommendations for initial controller or step-up therapy?
- What is the preferred therapy when initiating daily controller medications?
- Are the child's respiratory symptoms controlled?
- What is the Test for Respiratory and Asthma Control in Kids (TRACKTM)?7
- What are the next steps for a child with uncontrolled respiratory symptoms?
- How can caregivers help children achieve asthma control?
1. American Lung Association. Childhood Asthma
Overview. http://www.lungusa.org/site/pp.asp?c=dvLUK9O0E&b=22782. Published April 2008.
Accessed January 16, 2009.
2. American Lung Association Epidemiology and
Statistics Unit Research and Program Services
Division. Trends in Asthma Morbidity and Mortality.
http://www.lungusa.org/atf/cf/%7B7A8D42C2-FCCA-4604-8ADE-7F5D5E762256%7D/ASTHMA%20JAN%202009.PDF. Published January 2009.
Accessed February 13, 2009.
3. GlaxoSmithKline. Children & Asthma in America.
Executive Summary. http://www.asthmainamerica.com/children_index.html. Accessed March 18, 2009.
4. Akinbami L; Centers for Disease Control and
Prevention National Center for Health Statistics. The
state of childhood asthma, United States, 1980-2005.
Adv Data. 2006;381:1-24.
5. Bisgaard H, Szefler S. Prevalence of asthma-like
symptoms in young children. Pediatr Pulmonol.
6. National Asthma Education and Prevention
Program. Expert Panel Report 3: Guidelines for the
Diagnosis and Management of Asthma. Full Report
2007. http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm. Accessed July 22, 2009.
7. Murphy KR, Zeiger RS, Kosinski M, et al. Test for
respiratory and asthma control in kids (TRACK): a
caregiver-completed questionnaire for preschool-aged
children. J Allergy Clin Immunol. 2009;123:833-9.e9.
8. Chipps BE, Spahn JD, Sorkness CA, et al. Variability
in asthma severity in pediatric subjects with asthma
previously receiving short-acting beta2-agonists.
J Pediatr. 2006;148:517-521.
9. Global Initiative for Asthma (GINA). Global
Strategy for the Diagnosis and Management of
Asthma in Children 5 Years and Younger. http://www.ginasthma.com. Accessed July 2009.
10. Eigen H. Differential diagnosis and treatment
of wheezing and asthma in young children. Clin
Pediatr (Phila). 2008;47:735-743.
11. Pedersen S. Preschool asthma—not so easy to
diagnose [letter]. Prim Care Respir J. 2007;16:4-6.
12. Martinez FD, Wright AL, Taussig LM, et al.
Asthma and wheezing in the first six years of life.
The Group Health Medical Associates. N Engl J
13. Taussig LM, Wright AL, Holberg CJ, et al.
Tucson Children's Respiratory Study: 1980 to present.
J Allergy Clin Immunol. 2003;111:661-675.
14. Castro-Rodriguez JA, Garcia-Marcos L. Wheezing
and asthma in childhood: an epidemiology approach.
Allergol Immunopathol (Madr). 2008;36:280-290.
15. Castro-Rodríguez JA, Holberg CJ, Wright AL,
Martinez FD. A clinical index to define risk of asthma
in young children with recurrent wheezing. Am
J Respir Crit Care Med. 2000;162(4 pt 1):1403-1406.
16. Bush A. Update in pediatric lung disease 2008.
Am J Respir Crit Care Med. 2009;179:637-649.
17. Heikkinen T, Järvinen A. The common cold.
18. Johnston NW, Johnston SL, Norman GR, et al.
The September epidemic of asthma hospitalization:
school children as disease vectors [published correction
appears in J Allergy Clin Immunol. 2007;
120:47]. J Allergy Clin Immunol. 2006;117:557-562.
19. Van Dole KB, Swern AS, Newcomb K, Nelsen
L. Seasonal patterns in health care use and pharmaceutical
claims for asthma prescriptions for preschool-
and school-aged children. Ann Allergy
Asthma Immunol. 2009;102;198-204.
20. Sears MR, Johnston NW. Understanding the
September asthma epidemic. J Allergy Clin Immunol.
21. Dales RE, Schweitzer I, Toogood JH, et al.
Respiratory infections and the autumn increase in
asthma morbidity. Eur Respir J. 1996;9:72-77.
22. Guilbert TW, Morgan WJ, Krawiec M, et al.
The Prevention of Early Asthma in Kids study:
design, rationale and methods for the Childhood
Asthma Research and Education network. Control
Clin Trials. 2004;25:286-310.
23. Nickel R, Kulig M, Forster J, et al. Sensitization
to hen's egg at the age of twelve months is predictive
for allergic sensitization to common indoor and
outdoor allergens at the age of three years. J Allergy
Clin Immunol. 1997;99:613-617.
24. Kulig M, Bergmann R, Tacke U, et al; The MAS
Study Group, Germany. Long-lasting sensitization to
food during the first two years precedes allergic airway
disease. Pediatr Allergy Immunol. 1998;9:61-67.
25. Guilbert TW, Morgan WJ, Zeiger RS, et al. Atopic
characteristics of children with recurrent wheezing
at high risk for the development of childhood asthma.
J Allergy Clin Immunol. 2004;114:1282-1287.
26. Guilbert TW, Morgan WJ, Zeiger RS, et al.
Long-term inhaled corticosteroids in preschool children
at high risk for asthma. N Engl J Med. 2006;
27. Castro-Rodriguez JA, Rodrigo GJ. Efficacy of inhaled
corticosteroids in infants and preschoolers with
recurrent wheezing and asthma: a systematic review
with meta-analysis. Pediatrics. 2009;123:e519-e525.
28. Szefler SJ, Eigen H. Budesonide inhalation suspension:
a nebulized corticosteroid for persistent
asthma. J Allergy Clin Immunol. 2002;109:730-742.
29. Knorr B, Franchi LM, Bisgaard H, et al. Montelukast,
a leukotriene receptor antagonist, for the
treatment of persistent asthma in children aged 2 to
5 years. Pediatrics. 2001;108:e48.
30. Bisgaard H, Zielen S, Garcia-Garcia ML, et al.
Montelukast reduces asthma exacerbations in
2- to 5-year-old children with intermittent asthma.
Am J Respir Crit Care Med. 2005;171:315–322.
31. Garcia Garcia ML, Wahn U, Gilles L, et al.
Montelukast, compared with fluticasone, for control
of asthma among 6- to 14-year-old patients with mild
asthma: the MOSAIC study [published correction
appears in Pediatrics. 2005;116:1058]. Pediatrics.
32. Ostrom NK, Decotiis BA, Lincourt WR, et al.
Comparative efficacy and safety of low-dose fluticasone
propionate and montelukast in children with
persistent asthma. J Pediatr. 2005;147:213-220.
33. Sorkness CA, Lemanske RF Jr, Mauger DT, et
al; Childhood Asthma Research and Education Network
of the National Heart, Lung, and Blood Institute.
Long-term comparison of 3 controller regimens
for mild-moderate persistent childhood asthma: the
Pediatric Asthma Controller Trial [published correction
appears in J Allergy Clin Immunol. 2007;120:285].
J Allergy Clin Immunol. 2007;119:64-72.
34. Tasche MJ, Uijen JH, Bernsen RM, et al.
Inhaled disodium cromoglycate (DSCG) as maintenance
therapy in children with asthma: a systematic
review. Thorax. 2000;55:913-920.
35. Liu AH, Zeiger R, Sorkness C, et al. Development
and cross-sectional validation of the Childhood
Asthma Control Test. J Allergy Clin Immunol. 2007;
36. Skinner EA, Diette GB, Algatt-Bergstrom PJ,
et al. The Asthma Therapy Assessment Questionnaire
(ATAQ) for children and adolescents. Dis Manag.
37. Zorc JJ, Pawlowski NA, Allen JL, et al. Development
and validation of an instrument to measure
asthma symptom control in children. J Asthma.
38. Juniper EF, O'Byrne PM, Guyatt GH, et al. Development
and validation of a questionnaire to measure
asthma control. Eur Respir J. 1999;14:902-907.
39. Juniper EF, O'Byrne PM, Ferrie PJ, et al.
Measuring asthma control. Clinic questionnaire or
daily diary? Am J Respir Crit Care Med. 2000;
162(4 pt 1):1330-1334.
40. Nathan RA, Sorkness CA, Kosinski M, et al.
Development of the asthma control test: a survey for
assessing asthma control. J Allergy Clin Immunol.
41. Vollmer WM, Markson LE, O'Connor E, et al.
Association of asthma control with health care
utilization and quality of life. Am J Respir Crit Care
Med. 1999;160(5 pt 1):1647-1652.
42. Lara M, Duan N, Sherbourne C, et al. Differences
between child and parent reports of symptoms among
Latino children with asthma. Pediatrics. 1998;102:E68.
43. Erickson SR, Munzenberger PJ, Plante MJ,
et al. Influence of sociodemographics on the healthrelated
quality of life of pediatric patients with asthma
and their caregivers. J Asthma. 2002;39:107-117.
44. Halterman JS, McConnochie KM, Conn KM,
et al. A potential pitfall in provider assessments of
the quality of asthma control. Ambul Pediatr. 2003;
45. Bloomberg GR, Banister C, Sterkel R, et al.
Socioeconomic, family, and pediatric practice factors
that affect level of asthma control. Pediatrics. 2009;