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Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms - UpToDate

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Asthma in children younger than 12 years: Quick-relief

(rescue) treatment for acute symptoms
AUTHORS: Gregory Sawicki, MD, MPH, Kenan Haver, MD
SECTION EDITORS: Robert A Wood, MD, Gregory Redding, MD
DEPUTY EDITOR: Elizabeth TePas, MD, MS

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Aug 2024.

This topic last updated: Mar 28, 2023.

INTRODUCTION

Quick-relief (also called rescue or acute symptom relief) medications are primarily taken to
relieve the bronchoconstriction that occurs with acute asthma symptoms (eg, wheeze, cough,
chest tightness, shortness of breath), although some agents may have additional effects. Quick-
relief agents include short-acting beta agonists (SABAs), rapid-onset long-acting beta agonists
(LABAs) either alone or in combination with an inhaled glucocorticoid, and an anticholinergic
bronchodilator (eg, ipratropium bromide) alone or in combination with a SABA.

Medications initiated by the patient/caregiver for the quick relief of asthma symptoms in
children younger than 12 years of age are reviewed here. The recommendations below are
based upon National Asthma Education and Prevention Program (NAEPP) expert panel
guidelines published in 2007 [1] and updated in 2020 [2] and Global Initiative for Asthma (GINA)
2020 guidelines [3], which are similar to other major published asthma guidelines. (See 'Society
guideline links' below.)

Home management of more significant symptoms associated with an asthma exacerbation are
reviewed in detail separately. The outpatient and hospital management of acute asthma
exacerbations in children are also discussed in detail elsewhere. (See "Acute asthma
exacerbations in children younger than 12 years: Overview of home/office management and
severity assessment" and "Acute asthma exacerbations in children younger than 12 years:
Emergency department management" and "Acute asthma exacerbations in children younger

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than 12 years: Inpatient management" and "Acute severe asthma exacerbations in children
younger than 12 years: Intensive care unit management".)

Prophylactic use of SABAs prior to anticipated triggers (eg, exercise, allergen exposure) is
discussed in detail separately. (See "Beta agonists in asthma: Acute administration and
prophylactic use", section on 'Use in exercise-induced asthma' and "Exercise-induced
bronchoconstriction" and "Beta agonists in asthma: Acute administration and prophylactic use",
section on 'Allergen-induced asthma'.)

TYPES OF QUICK-RELIEF MEDICATIONS

Short-acting beta agonists (SABAs) are the most commonly used medications for the quick relief
of acute asthma symptoms [1-3]. Other medications used in select patient populations include a
combination of an inhaled glucocorticoid and a rapid-onset, long-acting beta agonist (LABA; eg,
budesonide-formoterol) and the anticholinergic agent ipratropium bromide in combination with
a SABA.

Short-acting beta agonists (SABAs)

Specific preparations

● Racemic albuterol – A racemic mixture of albuterol (salbutamol) is the primary SABA used
for quick relief of acute asthma symptoms and exacerbations.

● Levalbuterol – Levalbuterol (Levosalbutamol), the R-enantiomer, is the active isomer of

racemic albuterol that confers the bronchodilator effects. Levalbuterol is approved in the
United States for treatment of bronchospasm in children ≥4 years of age via
hydrofluoroalkane (HFA) metered-dose inhaler (MDI) and ≥6 years of age via solution for
nebulization.

Available data do not support widespread use of levalbuterol instead of racemic albuterol
as a quick-relief medication. Some studies have demonstrated favorable efficacy and
safety profiles for levalbuterol compared with racemic albuterol, including one in which
the hospitalization rate was lower among children who received levalbuterol in the
emergency department (ED; 36 versus 45 percent) [4-7]. However, overall clinical studies
suggest no meaningful benefits of levalbuterol over racemic albuterol [8-11]. The 2007
National Asthma Education and Prevention Program (NAEPP) guidelines suggest that
levalbuterol provides clinically comparable bronchodilation and systemic side effects as
racemic albuterol [1].

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● Other SABAs – Other SABAs used in the management of childhood asthma include
terbutaline, clenbuterol, and fenoterol. Inhaled forms of these medications are available in
some countries (not the United States), although not all are approved for use in children
younger than 12 years.

Route of delivery

● Inhaled – Inhaled SABAs ( table 1) have the advantages of lower doses, fewer side
effects, and more rapid onset of action than oral agents [12].

Inhaled SABAs are typically administered by an MDI (through a valved holding chamber if
an aerosol, but not if an inhalation powder) or by nebulization, along with an infant- or
child-sized mask as appropriate for size and developmental age [13]. A number of factors
influence the amount of drug actually deposited in the lower airways with either of these
methods [14]. In general, administration by MDI is preferred, although this is based upon
ED data in which higher doses of SABA are typically used compared with home
administration (4 to 12 puffs rather than 2 puffs) [15]. (See "Acute asthma exacerbations in
children younger than 12 years: Emergency department management", section on
'Inhaled short-acting beta-2 agonists' and "Delivery of inhaled medication in children",
section on 'Factors affecting drug deposition' and "Use of medication nebulizers in
children" and "The use of inhaler devices in children".)

A dry powder inhaler (DPI) SABA is also available for children ≥4 years of age [16].
However, it is not known whether an acute exacerbation reduces inspiratory flow enough
in this age group to reduce drug delivery when using a DPI. Thus, the authors are
comfortable with DPI SABA use for prophylactic treatment prior to exercise in those who
can demonstrate proper use of the device but would not advise its use in the acute setting
as rescue therapy.

It is important for patients who use inhalers to know how to tell when the inhaler is near
empty to ensure that they will have access to bronchodilator therapy during an acute
exacerbation. Many MDIs now have a built-in counter. Patients should only use the
actuator supplied with the MDI (if they have more than one SABA inhaler, such as one for
home and one for camp or school) to ensure that the count is accurate. (See "The use of
inhaler devices in children", section on 'Determining when an MDI is empty'.)

● Oral – Oral beta agonists (albuterol) are no longer used for quick-relief treatment because
they have more frequent and greater systemic effects, such as tachycardia, tremor, and
behavioral and sleep disturbance, and a slower onset of action compared with inhaled
SABAs.
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Dosing — The usual doses of inhaled SABAs used for intermittent asthma symptoms are
reviewed in the table ( table 1). Higher doses with shorter dosing intervals are often used for
more significant acute asthma exacerbations, particularly when administered in the ED or
inpatient setting ( table 2). Uses of SABAs in these settings is discussed in greater detail
separately. (See "Acute asthma exacerbations in children younger than 12 years: Overview of
home/office management and severity assessment", section on 'Home management' and
"Acute asthma exacerbations in children younger than 12 years: Overview of home/office
management and severity assessment", section on 'Outpatient management' and "Acute
asthma exacerbations in children younger than 12 years: Inpatient management", section on
'Management of bronchospasm' and "Acute asthma exacerbations in children younger than 12
years: Emergency department management", section on 'Inhaled short-acting beta-2 agonists'.)

Use of SABAs for exercise-induced bronchoconstriction is discussed in detail separately. (See

"Beta agonists in asthma: Acute administration and prophylactic use", section on 'Use in
exercise-induced asthma' and "Exercise-induced bronchoconstriction", section on 'Pre-exercise
treatments for EIB'.)

Adverse effects — The most common side effects are tremor, increased heart rate, and
palpitations. SABAs should not be prescribed on a regular schedule, because of concerns about
a possible relationship between the frequent use of these agents and deteriorating asthma
control [1,17]. In addition, scheduled use prevents assessment of frequency of need based upon
signs and symptoms, an important element in evaluating the status of an exacerbation.
Decreased sensitivity or tolerance to beta agonists with chronic use (tachyphylaxis) is primarily
mediated by downregulation of beta-2 adrenergic receptors. Various factors associated with
bronchodilator unresponsiveness include genetics [18], obesity [19], and stress [20]. Beta
agonist toxicity and tolerance are discussed in detail separately. (See "Beta agonists in asthma:
Acute administration and prophylactic use", section on 'Adverse effects' and "Beta agonists in
asthma: Acute administration and prophylactic use", section on 'Tolerance' and "Severe asthma
phenotypes", section on 'Asthma associated with obesity' and "Genetics of asthma".)

Combination inhaled glucocorticoid and beta agonist — Clinical studies have shown that use
of inhaled glucocorticoids in conjunction with beta agonists in patients with acute severe
asthma can enhance bronchodilator response to beta agonists by reversing beta receptor
desensitization and downregulation [21]. In a reciprocal manner, beta agonists influence the
activated glucocorticoid receptors. These findings have led to the use of inhaled glucocorticoids
with a SABA or a rapid-onset LABA for acute symptoms in select patient populations with
asthma. The inhaled glucocorticoid ( table 3) and SABA ( table 1) are used at standard
doses. The LABA most extensively studied for single maintenance and reliever therapy (SMART)

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is formoterol, which has a rapid onset of action and a maximum daily dose that allows for more
than twice a day use. The maximum daily dose of formoterol in children 4 to 11 years of age is
36 micrograms, equivalent to 8 puffs of budesonide-formoterol MDI. While this dosing is off
label, it is supported by national and international guidelines and clinical trials ( table 4A-B)
[2,3] (see 'Acute symptoms in patients with persistent asthma' below). Other inhaled
glucocorticoid-formoterol combinations that are available in some countries but that have not
been studied or approved for SMART and have slightly higher doses of formoterol are
mometasone-formoterol and beclomethasone-formoterol. Adverse effects from inhaled
glucocorticoids are infrequent with intermittent use. The adverse effects of inhaled
glucocorticoids are discussed in detail separately. (See "Molecular effects of inhaled
glucocorticoid therapy in asthma", section on 'Beta 2-receptor effects' and "Major side effects of
inhaled glucocorticoids".)

Ipratropium bromide — Ipratropium bromide is an anticholinergic drug that provides

bronchodilation through smooth muscle relaxation [22]. However, it has a slower onset of
action than SABAs. It begins to work within 15 to 30 minutes, with a maximum effect seen
within one to two hours. Inhaled anticholinergics used on their own are less effective than
inhaled beta agonists used alone or in combination with anticholinergics [23]. Ipratropium can
be administered via MDI and spacer or via nebulizer. Potential adverse effects of ipratropium
bromide include drying of the mouth, blurred vision, urinary retention, tachycardia, and central
nervous system effects. Ipratropium is commonly used in combination with a SABA for asthma
exacerbations treated in the ED. It is occasionally used in combination with albuterol for quick
relief of acute symptoms in patients with asthma who have demonstrated a prior favorable
response. (See "Acute asthma exacerbations in children younger than 12 years: Emergency
department management", section on 'Ipratropium bromide'.)

Nonstandard therapies — Experimental and alternative therapies, including over-the-counter

products such as homeopathic treatments [24] and racemic epinephrine inhalers [25-27], are
not recommended for routine care of acute asthma symptoms. These therapies are discussed in
greater detail separately. (See "Acute exacerbations of asthma in adults: Home and office
management", section on 'Risks associated with inhaled epinephrine' and "Investigational
agents for asthma" and "Complementary, alternative, and integrative therapies for asthma".)

QUICK-RELIEF TREATMENT

Overview — Short-acting beta agonists (SABAs) such as albuterol (salbutamol) and levalbuterol
(levosalbutamol) remain a cornerstone of the treatment of childhood asthma ( table 4A-B) [1-
3]. SABAs relax airway smooth muscle, reducing constriction, which leads to a prompt increase
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in airflow [28-33]. These drugs generally provide rapid relief of acute asthma symptoms (eg,
coughing, wheezing, chest tightness, and shortness of breath), with a time to onset of action of
approximately 5 to 10 minutes, peak effect beginning within approximately 50 minutes, and
duration of action of approximately three to six hours. SABAs are the standard emergency
treatment for acute asthma exacerbations in all patients based upon adult data, a few early
trials in children, and many ensuing years of clinical use. By extrapolation, as-needed use of
these drugs is also the primary therapy for acute symptoms in patients with intermittent
asthma. (See "Beta agonists in asthma: Acute administration and prophylactic use" and "Acute
asthma exacerbations in children younger than 12 years: Emergency department
management", section on 'Inhaled short-acting beta-2 agonists'.)

Acute symptoms in patients with intermittent asthma/wheezing — We suggest a SABA as

needed for acute symptoms in all children with intermittent asthma ( table 4A-B) [1-3]. Taking
a low-dose inhaled glucocorticoid whenever a SABA is used is an alternative to a SABA alone in
children >5 years of age. A short course of a high-dose inhaled glucocorticoid starting at the
onset of a respiratory illness for 7 to 10 days in addition to a SABA as needed may be used in
patients ≤4 years of age with intermittent virus-induced wheezing. This approach to treatment
of recurrent virus-induced wheezing in young children is discussed in greater detail separately.
(See "Treatment of recurrent virus-induced wheezing in young children", section on 'Episodic
therapy'.)

Acute symptoms in patients with persistent asthma — We recommend an as-needed SABA

for quick-relief therapy in the following patients ( table 4A-B) [1-3]:

● Children <4 years of age with any severity of persistent asthma

● Children 4 to 11 years of age with mild persistent asthma
● Children 4 to 11 years of age with severe persistent asthma on step 5 or step 6 therapy

For children ≥4 years of age with moderate-to-severe persistent asthma on step 3 or step 4
therapy, we suggest an inhaled glucocorticoid combined with a rapid-onset long-acting beta
agonist (LABA; eg, formoterol) for both daily and quick-relief therapy (single maintenance and
reliever therapy [SMART]) rather than a SABA for quick-relief therapy. The goal of SMART is to
both treat acute symptoms and prevent exacerbations. It is reasonable to continue a SABA for
quick-relief therapy in patients whose asthma is adequately controlled on a daily combination
inhaled glucocorticoid-LABA.

The recommendations for SMART are largely based upon adolescent and adult data. One post-
hoc analysis of data from a larger randomized trial that included 341 children 4 to 11 years of
age (118 on budesonide-formoterol 80-4.5 microg once daily with up to seven additional quick-

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relief puffs daily [SMART]; 117 on budesonide-formoterol 80-4.5 microg once daily with a SABA,
terbutaline, as needed for quick relief; and 106 on budesonide 320 microg daily with terbutaline
for quick relief) was performed [34,35]. Compared with the other treatment groups, children on
SMART had fewer exacerbations (14 versus 38 and 26 percent, respectively) and courses of oral
glucocorticoids (0.05 versus 0.3 and 0.25 courses/year, respectively), as well as a longer time to
first severe exacerbation. Growth was also significantly better in the two groups of children on
budesonide-formoterol versus the higher daily dose of budesonide (approximately 1 cm
adjusted mean difference in growth). (See "Initiating asthma therapy and monitoring in
adolescents and adults", section on 'Low-dose maintenance and reliever therapy (MART)' and
"Initiating asthma therapy and monitoring in adolescents and adults", section on 'Preferred
options' and "Ongoing monitoring and titration of asthma therapies in adolescents and adults",
section on 'Increasing (stepping up) therapy, for persistent poor symptom control'.)

Acute exacerbations — The initial at-home approach to treatment of acute exacerbations is

similar to that for isolated acute symptoms outlined above. Home management of more
significant symptoms associated with an asthma exacerbation are reviewed in detail separately.
The outpatient, emergency department (ED), and hospital management of acute asthma
exacerbations in children are also discussed in detail elsewhere. (See "Acute asthma
exacerbations in children younger than 12 years: Overview of home/office management and
severity assessment" and "Acute asthma exacerbations in children younger than 12 years:
Emergency department management" and "Acute asthma exacerbations in children younger
than 12 years: Inpatient management" and "Acute severe asthma exacerbations in children
younger than 12 years: Intensive care unit management".)

Prophylaxis — SABAs can be used preventively in patients with well-controlled asthma who
have symptoms with exercise and/or allergen exposure. An alternative in adolescents and
adults is a combination inhaled glucocorticoid and rapid-onset LABA, but this option has not
been adequately studied in younger children. LABAs should not be used as monotherapy.
Ipratropium is generally not used due to its slower onset of action. Prophylactic use of SABAs
prior to anticipated triggers (eg, exercise, allergen exposure) is discussed in detail separately.
(See "Beta agonists in asthma: Acute administration and prophylactic use", section on 'Use in
exercise-induced asthma' and "Exercise-induced bronchoconstriction", section on 'Pre-exercise
treatments for EIB' and "Beta agonists in asthma: Acute administration and prophylactic use",
section on 'Allergen-induced asthma'.)

SOCIETY GUIDELINE LINKS

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Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Asthma in children".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics."
The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading
level, and they answer the four or five key questions a patient might have about a given
condition. These articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more
sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading
level and are best for patients who want in-depth information and are comfortable with some
medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print
or e-mail these topics to your patients. (You can also locate patient education articles on a
variety of subjects by searching on "patient info" and the keyword(s) of interest.)

● Basics topics (see "Patient education: Asthma in children (The Basics)" and "Patient
education: How to use your child's metered dose inhaler (The Basics)")

● Beyond the Basics topic (see "Patient education: Asthma treatment in children (Beyond the
Basics)")

SUMMARY AND RECOMMENDATIONS

● Roles and types of quick-relief asthma medications – Quick-relief medications are

primarily taken to relieve the bronchoconstriction that occurs with acute asthma
symptoms, although some agents may have additional effects. The most commonly used
quick-relief agents are a short-acting beta agonist (SABA) alone, a SABA plus an inhaled
glucocorticoid, and a rapid-onset long-acting beta agonist (LABA) in combination with an
inhaled glucocorticoid. (See 'Introduction' above and 'Types of quick-relief medications'
above.)

● Short-acting beta agonists – Inhaled SABAs are the mainstay of management of acute
asthma symptoms and exacerbations ( table 1). These drugs generally provide rapid
relief of acute asthma symptoms (eg, coughing, wheezing, chest tightness, and shortness
of breath). (See 'Short-acting beta agonists (SABAs)' above.)

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● Combined glucocorticoids and beta agonists – Inhaled glucocorticoids and beta

agonists work in a reciprocal manner, enhancing the response to the other drug when
used concomitantly. (See 'Combination inhaled glucocorticoid and beta agonist' above.)

● Approach to quick-relief therapy – Our suggested approach to providing quick-relief

(rescue) therapy for children with asthma is as follows:

• Moderate-to-severe persistent asthma – For children 4 to 11 years of age with

moderate-to-severe persistent asthma on step 3 or step 4 therapy, we suggest an
inhaled glucocorticoid combined with a rapid-onset LABA (eg, formoterol) for both daily
and quick-relief therapy (single maintenance and reliever therapy [SMART]) rather than
a SABA for quick-relief therapy (Grade 2C). For children 4 to 11 years of age with severe
persistent asthma on step 5 or 6 therapy, we suggest a SABA for quick-relief therapy
rather than SMART (Grade 2C). (See 'Acute symptoms in patients with persistent
asthma' above.)

• Intermittent and mild persistent asthma – For most children with less severe
asthma (step 1 or step 2) who require quick-relief (rescue) medication, we suggest
treatment with a SABA alone rather than in combination with an inhaled glucocorticoid
(Grade 2C). Taking a low-dose inhaled glucocorticoid whenever a SABA is used is an
alternative to a SABA alone in children >5 years of age who are not on daily controller
therapy. (See 'Acute symptoms in patients with persistent asthma' above and 'Acute
symptoms in patients with intermittent asthma/wheezing' above.)

• Young children with intermittent virus-induced wheezing - In young children (≤4

years old) with intermittent virus-induced wheezing, a short course of a high-dose
inhaled glucocorticoid may be used starting at the onset of a respiratory illness in
addition to as-needed SABA. This is discussed separately. (See "Treatment of recurrent
virus-induced wheezing in young children", section on 'Intermittent preventive
therapy'.)

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22. Jones CA, Madison JM, Tom-Moy M, Brown JK. Muscarinic cholinergic inhibition of adenylate
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23. Teoh L, Cates CJ, Hurwitz M, et al. Anticholinergic therapy for acute asthma in children.
Cochrane Database Syst Rev 2012; :CD003797.
24. Over-the-Counter Asthma Products Labeled as Homeopathic: FDA Statement - Consumer W
arning About Potential Health Risks. http://www.fda.gov/safety/medwatch/safetyinformatio
n/safetyalertsforhumanmedicalproducts/ucm439014.htm.

25. Safety Concerns with Asthmanefrin and the EZ Breathe Atomizer. http://www.fda.gov/Drug
s/DrugSafety/ucm370483.htm.
26. Canadian Society of Allergy and Clinical Immunology: Non-prescription availability of theop
hylline, epinephrine and ephedrine for asthma. http://csaci.ca/index.php?page=359.

27. Mondal P, Kandala B, Ahrens R, et al. Nonprescription racemic epinephrine for asthma. J
Allergy Clin Immunol Pract 2014; 2:575.

28. Camargo CA Jr, Spooner CH, Rowe BH. Continuous versus intermittent beta-agonists in the
treatment of acute asthma. Cochrane Database Syst Rev 2003; :CD001115.
29. Karpel JP, Aldrich TK, Prezant DJ, et al. Emergency treatment of acute asthma with albuterol
metered-dose inhaler plus holding chamber: how often should treatments be
administered? Chest 1997; 112:348.
30. Rudnitsky GS, Eberlein RS, Schoffstall JM, et al. Comparison of intermittent and
continuously nebulized albuterol for treatment of asthma in an urban emergency
department. Ann Emerg Med 1993; 22:1842.
https://www.uptodate.com/contents/asthma-in-children-younger-than-12-years-quick-relief-rescue-treatment-for-acute-symptoms/print?sectionName… 11/35
1/10/24, 6:19 a.m. Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms - UpToDate

31. Lin RY, Sauter D, Newman T, et al. Continuous versus intermittent albuterol nebulization in
the treatment of acute asthma. Ann Emerg Med 1993; 22:1847.
32. Ben-Zvi Z, Lam C, Hoffman J, et al. An evaluation of the initial treatment of acute asthma.
Pediatrics 1982; 70:348.

33. Rossing TH, Fanta CH, Goldstein DH, et al. Emergency therapy of asthma: comparison of
the acute effects of parenteral and inhaled sympathomimetics and infused aminophylline.
Am Rev Respir Dis 1980; 122:365.

34. O'Byrne PM, Bisgaard H, Godard PP, et al. Budesonide/formoterol combination therapy as
both maintenance and reliever medication in asthma. Am J Respir Crit Care Med 2005;
171:129.
35. Bisgaard H, Le Roux P, Bjåmer D, et al. Budesonide/formoterol maintenance plus reliever
therapy: a new strategy in pediatric asthma. Chest 2006; 130:1733.
Topic 5743 Version 32.0

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GRAPHICS

Asthma medications for acute symptom relief in children <12 years of age *

0 to <4
Medication Dose form 4 to 11 years Comments
years

Inhaled short-acting beta2-agonists (SABAs)

Metered dose inhaler (MDI)

Albuterol 90 mcg/puff 2 puffs up 2 puffs up to Differences in

(salbutamol) to every 4 every 4 potencies exist, but
HFA MDI with hours as hours as products shown are
spacer (valved needed needed essentially
holding comparable on a
chamber) per-puff basis.
An increasing use or
lack of expected
effect indicates
diminished control
of asthma.
Not recommended
for long-term daily
treatment. Regular
use exceeding 2
days/week for
symptom control
(not prevention of
EIB) indicates the
need for additional
long-term control
Levalbuterol 45 mcg/puff Safety and 2 puffs up to therapy.
(levosalbutamol) efficacy every 4 Periodically clean
HFA MDI with not hours as mouthpiece as drug
spacer (valved established needed may plug orifice.
holding in children Inhaler should be
chamber) <4 years administered using
a valved holding
chamber; add a
mask for children <4
years of age.
Instructions for use,
priming, and
cleaning MDI vary b

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1/10/24, 6:19 a.m. Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms - UpToDate

brand. For specific

information, refer to
UpToDate topic on
use of inhaler
devices in children,
UpToDate Lexidrug,
and patient leaflet
included with MDI.
Dry powder inhaler (DPI)

Albuterol 90 Safety and 2 puffs up to DPI alternative for

(salbutamol) mcg/inhalation efficacy every 4 prophylactic use
breath-activated not hours as prior to exercise in
DPI established needed older children who
in children are comfortable with
<4 years and capable of
properly using a
breath-activated
inhaler technique.
Use of DPI is not
advised as rescue
therapy in an acute
setting, as some
children may be
unable to generate
sufficient inspiratory
flow rate to assure
optimal lung
deposition of drug.
NOTE: DPIs can
contain lactose and
trace milk proteins
(ie, potential
allergens).
Also refer to
information above
on albuterol MDI.

Nebulizer solution

Albuterol 0.63 mg/3 mL 0.63 to 2.5 1.25 to 5 mg May mix with

(salbutamol) 1.25 mg/3 mL mg up to up to every 4 budesonide
2.5 mg/3 mL every 4 hours, as suspension,
hours, as needed ipratropium
5 mg/mL
needed solution, or
(0.5%)
cromolyn sodium

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solution for
nebulization.

Levalbuterol 0.31 mg/3 mL 0.31 to 0.31 to 0.63 May mix with

(levosalbutamol) 0.63 mg/3 mL 1.25 mg up mg up to budesonide
1.25 mg/0.5 to every 4 every 4 suspension for
mL hours, as hours, as nebulization.
needed needed
1.25 mg/3 mL

Combination inhaled rapid-onset long-acting beta agonist and glucocorticoid

Budesonide- Budesonide 80 Safety and 1 to 2 Single maintenance

formoterol MDI mcg- efficacy inhalations and reliever therapy
formoterol 4.5 not every 4 (SMART) is off-label
mcg/puff established hours, as in the US. Studies of
in children needed, in SMART used DPI,
<6 years addition to 2 but only the MDI is
inhalations available in the US.
daily as There is a small
maintenance amount of variability
therapy in the amount of
(maximum drug dispensed with
total daily each MDI actuation,
dose 8 puffs) whereas the DPI
dosing is consistent
Thus, 2 puff dosing
is preferred for the
MDI.

Use and dose adjustment of inhaled short-acting beta2-agonists for acute asthma exacerbations are
reviewed separately. Short-acting beta agonists (SABAs) can also be used to prevent exercise-induced
bronchoconstriction, 2 inhalations administered 10 to 20 minutes prior to exercise. In addition, higher
doses of SABAs may be used to treat acute exacerbations, and they may be given more frequently
than every 4 hours when patients are in a medically supervised, urgent-care setting. Refer to separate
UpToDate topic reviews and tables on recommended doses of medications to treat children with an
acute asthma exacerbation.
Nonselective inhaled agents (ie, epinephrine, isoproterenol, metaproterenol) and orally administered
beta2-agonists are not recommended, due to their potential for excessive cardiac stimulation,
especially in high doses.

DPI: dry powder inhaler; EIB: exercise-induced bronchospasm; HFA: hydrofluoroalkane; MDI: metered-
dose inhaler.

* Doses are provided for those products that have been approved by the US Food and Drug
Administration or have sufficient clinical trial safety and efficacy data in the appropriate age ranges to
support their use. Doses shown and strengths (ie, mcg per puff or inhalation) are based upon product

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1/10/24, 6:19 a.m. Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms - UpToDate

descriptions approved in the United States, which may differ from how strengths are described for
products available in other countries. Consult local product information before use.

Data from:
1. National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of
Asthma. NIH Publication no. 08-4051, 2007.
2. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and
Prevention Program Coordinating Committee Expert Panel Working Group. Available at: https://www.nhlbi.nih.gov/health-
topics/all-publications-and-resources/2020-focused-updates-asthma-management-guidelines (Accessed on October 18,
2021).
3. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, updated 2021.
https://ginasthma.org/reports/ (Accessed on October 18, 2021).
4. UpToDate Lexidrug. More information available at https://online.lexi.com/.

Graphic 59229 Version 24.0

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Inhaled beta agonist doses used for initial management of asthma

exacerbations in children <12 years of age *

Medication Dose form 0 to <4 years 4 to 11 years Comments

Metered dose inhaler (MDI)

Albuterol 90 mcg/puff Home Home Differences in

(salbutamol) management – management – potencies exist,
HFA MDI with 2 to 4 2 to 4 but products
spacer (valved inhalations, can inhalations, can shown are
holding be repeated be repeated essentially
chamber) every 20 every 20 comparable on
minutes for a minutes for a per-puff basis.
total of 3 doses, total of 3 doses, An increasing
then up to then up to use or lack of
every 4 hours every 4 hours expected effect
as directed ¶ as directed ¶ indicates
Acute care Acute care diminished
setting – 4 to 8 setting – 4 to 8 control of
inhalations inhalations asthma.
every 20 every 20 Not
minutes for 3 minutes for 3 recommended
doses Δ , then doses Δ , then for long-term
up to every 1 up to every 1 daily treatment.
hour as needed hour as needed Regular use
exceeding 2
days/week for
symptom
control (not
prevention of
EIB) indicates
the need for
Levalbuterol 45 mcg/puff Safety and Home additional long-
(levosalbutamol) efficacy not management – term control
HFA MDI with established in 2 to 4 therapy.
spacer (valved children <4 inhalations, can Periodically
holding years be repeated clean
chamber) every 20 mouthpiece as
minutes for a drug may plug
total of 3 doses, orifice.
then up to
Instructions for
every 4 hours
use, priming,
as directed ¶
and cleaning
MDI vary by

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Acute care brand. For

setting – 4 to 8 specific
inhalations information,
every 20 refer to
minutes for 3 UpToDate topic
doses Δ , then on use of
up to every 1 inhaler devices
hour as needed in children,
UpToDate
Lexidrug, and
patient leaflet
included with
MDI.
Dry powder inhaler (DPI)

Albuterol 90 Safety and Home DPI alternative

(salbutamol) mcg/inhalation efficacy not management – for prophylactic
breath-activated established in 2 to 4 use prior to
DPI children <4 inhalations, can exercise in older
years be repeated children who are
every 20 comfortable
minutes for a with and
total of 3 doses, capable of
then up to properly using a
every 4 hours breath-activated
as directed ¶ inhaler
technique.
Use of DPI is no
advised as
rescue therapy
in an acute
setting, as some
children may be
unable to
generate
sufficient
inspiratory flow
rate to assure
optimal lung
deposition of
drug.
NOTE: DPIs can
contain lactose
and trace milk
proteins (ie,

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1/10/24, 6:19 a.m. Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms - UpToDate

potential
allergens).
Also refer to
information
above on
albuterol MDI.

Nebulizer solution

Albuterol 0.63 mg/3 mL Home Home May mix with

(salbutamol) 1.25 mg/3 mL management – management – budesonide
2.5 mg/3 mL 1.25 to 2.5 mg, 2.5 to 5 mg, can suspension,
can be be repeated ipratropium
5 mg/mL
repeated every every 20 solution, or
(0.5%)
20 minutes for minutes for a cromolyn
a total of 3 total of 3 doses, sodium solution
doses, then up then up to for nebulization
to every 4 every 4 hours
hours as as directed ¶
directed ¶ Acute care
Acute care setting – 0.15
setting – 0.15 mg/kg per dose
mg/kg per dose (minimum 2.5
(minimum 2.5 mg, maximum
mg, maximum 5 mg/dose) up
5 mg/dose) up to every 20
to every 20 minutes for up
minutes for up to 3 doses,
to 3 doses, then 0.15 to 0.3
then 0.15 to 0.3 mg/kg
mg/kg (maximum 10
(maximum 10 mg) every 30
mg) up to every minutes to 4
30 minutes as hours as
needed or needed or
switch to switch to
continuous continuous
therapy if in a therapy if in a
critical care critical care
setting setting
Critical care Critical care
setting and setting and
severe severe
exacerbation – exacerbation –
Continuous Continuous
nebulizer nebulizer
treatment 0.5 treatment 0.5
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mg/kg per hour mg/kg per hour

(maximum 20 (maximum 20
mg per hour) mg per hour)
by large- by large-
volume volume
nebulizer nebulizer;
weight-based
Dose may also
dosing is also
be determined
an option (refer
based upon
to 0 to <4
body weight as
years)
follows:
5 to 10 kg –
5 to 7.5 mg
per hour
10 to 20 kg
– 10 to 12.5
mg per
hour
>20 kg – 15
to 20 mg
per hour

Levalbuterol 0.31 mg/3 mL Home Home May mix with

(levosalbutamol) 0.63 mg/3 mL management – management – budesonide
1.25 mg/0.5 0.63 to 1.25 0.63 to 1.25 suspension,
mL mg, can be mg, can be ipratropium
repeated every repeated every solution, or
1.25 mg/3 mL
20 minutes for 20 minutes for cromolyn
a total of 3 a total of 3 sodium solution
doses, then up doses, then up for nebulization
to every 4 to every 4
hours as hours as
directed ¶ directed ¶
Acute care Acute care
setting – 0.75 setting – 0.75
mg/kg per dose mg/kg per dose
(minimum 1.25 (minimum 1.25
mg, maximum mg, maximum
2.5 mg/dose) 2.5 mg/dose)
up to every 20 up to every 20
minutes for up minutes for up
to 3 doses, to 3 doses,
then 0.075 to then 0.075 to
0.15 mg/kg 0.15 mg/kg
(maximum 5 (maximum 5
mg) up to every mg) up to every
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30 minutes as 30 minutes as
needed needed
Critical care Critical care
setting and setting and
severe severe
exacerbation – exacerbation –
Continuous Continuous
nebulizer nebulizer
treatment 0.25 treatment 0.25
mg/kg per hour mg/kg per hour
(maximum 10 (maximum 10
mg per hour) mg per hour)
by large- by large-
volume volume
nebulizer nebulizer

Also refer to separate UpToDate topic reviews and table on recommended doses of medications other
than inhaled beta agonists to treat children with an acute asthma exacerbation.
Nonselective inhaled agents (ie, epinephrine, isoproterenol, metaproterenol) and orally administered
beta2-agonists are not recommended, due to their potential for excessive cardiac stimulation,
especially in high doses. For severely ill children, however, IM or SC epinephrine may be administered
for rapid relief.

EIB: exercise-induced bronchoconstriction; HFA: hydrofluoroalkane; IM: intramuscular; SC: subcutaneous.

* Doses are provided for those products that have been approved by the US Food and Drug
Administration or have sufficient clinical trial safety and efficacy data in the appropriate age ranges to
support their use. Doses shown and strengths (ie, mcg per puff or inhalation) are based upon product
descriptions approved in the United States, which may differ from how strengths are described for
products available in other countries. Consult local product information before use.

¶ Typically, 2 puffs are used for mild-to-moderate symptoms and 4 puffs for more severe symptoms
and/or for patients who are older and/or weigh more. Children (excluding infants) with more severe
symptoms may require up to 6 inhalations per dose. Over the course of these 3 short-acting beta agonist
treatments, the caregiver can determine (based on action plan or clinician guidance) whether to continue
care at home or seek additional medical attention.

Δ The number of inhalations is based up on the severity of respiratory impairment, age and weight of the
patient, number of inhalations the patient has already received, and availability of monitoring. When
administering an albuterol MDI for acute asthma exacerbation, use of a valved holding chamber (with a
mask in children <4 years of age) and careful attention to technique are recommended.

Data from:
1. National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of
Asthma. NIH Publication no. 08-4051, 2007.
2. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and
Prevention Program Coordinating Committee Expert Panel Working Group. https://www.nhlbi.nih.gov/health-topics/all-
publications-and-resources/2020-focused-updates-asthma-management-guidelines (Accessed on October 18, 2021).
https://www.uptodate.com/contents/asthma-in-children-younger-than-12-years-quick-relief-rescue-treatment-for-acute-symptoms/print?sectionName… 21/35
1/10/24, 6:19 a.m. Asthma in children younger than 12 years: Quick-relief (rescue) treatment for acute symptoms - UpToDate
3. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention, updated 2021.
https://ginasthma.org/reports/ (Accessed on October 18, 2021).
4. UpToDate Lexidrug. More information available at https://online.lexi.com/.

Graphic 134102 Version 7.0

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Estimated comparative daily doses for inhaled glucocorticoids in children

Low daily dose Medium daily dose High daily dose

Drug
Child 0 Child 0 Child 0
Child 5 to 11 Child 5 to 11 Child 5 to 1
to 4 to 4 to 4

Beclomethasone NA 40 mcg/puff - NA 40 mcg/puff - NA 80 mcg/puff -

HFA 1 to 2 puffs 2 to 4 puffs 3 to 4 puffs
twice per day twice per day twice per day
40 or 80
mcg/puff 80 mcg/puff -
1 to 2 puffs
twice per day

Budesonide DPI* NA 90 NA 180 NA 180

(breath activated) mcg/inhalation mcg/inhalation mcg/inhalatio
- 1 to 2 - 1 to 2 - 3 to 4
90 or 180
inhalations inhalations inhalations
mcg/inhalation
twice per day twice per day twice per day

Budesonide 0.25 to 0.5 mg once 0.75 to 1 1 mg once 1.25 to 2 2 mg once

nebulization 0.5 mg daily or as 2 mg once daily or as 2 mg once daily or as 2
suspension ¶ once divided doses daily or divided doses daily or divided doses
daily or as 2 or 3 as 2
0.25 mg/2 mL,
as 2 divided divided
0.5 mg/2 mL,
divided doses doses
or 1 mg/2 mL
doses

Ciclesonide HFA Δ NA 80 mcg/puff - NA 80 mcg/puff - NA 80 mcg/puff -

1 to 2 puffs 3 to 4 puffs 5 to 6 puffs
80 or 160
once daily once daily once daily or
mcg/puff
as 2 divided
doses

160 mcg/puff
3 puffs once
daily or as 2
divided doses

Fluticasone HFA ◊ 44 44 mcg/puff - 44 44 mcg/puff - 110 110 mcg/puff

mcg/puff 1 to 2 puffs mcg/puff 2 to 4 puffs mcg/puff 2 puffs twice
44, 110, or 220
- 2 puffs twice per day - 2 to 4 twice per day - 2 puffs per day
mcg/puff
twice per puffs twice per
110 mcg/puff - 220 mcg/puff
day ◊ twice per day
1 puff in AM 1 puff twice
day
and 2 puffs in 220 per day
110 PM mcg/puff
mcg/puff - 1 puff
- 1 puff
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in AM twice per
and 2 day
puffs in
PM

Fluticasone DPI NA 50 NA 50 NA 100

(breath mcg/inhalation mcg/inhalation mcg/inhalatio
activated) § - 1 to 2 - 3 to 4 - 2 inhalations
inhalations inhalations in AM and 3
50, 100, or 250
twice per day twice per day inhalations in
mcg/inhalation
PM
100
mcg/inhalation 250
- 1 inhalation mcg/inhalatio
in AM and 2 - 1 inhalation
inhalations in twice per day
PM to 2
inhalations
twice per day

Mometasone NA 110 NA 110 NA 110

aerosol DPI mcg/inhalation mcg/inhalation mcg/inhalatio
(breath - 1 inhalation - 2 to 3 - 4 inhalations
activated)* once daily inhalations once daily or
once daily inhalations
110 or 220
twice per day
mcg/inhalation
220
mcg/inhalatio
- 2 inhalations
once daily or
inhalation
twice per day

Mometasone HFA NA 50 mcg/puff - NA 50 mcg/puff - NA 100 mcg/puff

MDI 1 puff once or 2 to 3 puffs 2 puffs twice
twice per day twice per day per day
50, 100, or 200
mcg/puff 100 mcg/puff - 200 mcg/puff
1 puff twice 1 inhalation
per day twice per day

Some doses may be outside approved package labeling, especially in the high-dose range. Doses shown
and strengths (ie, mcg per puff or inhalation) are based upon product descriptions approved in the
United States, which may differ from how strengths are described for products available in other
countries. Consult local product information before use.

HFA: hydrofluoroalkane; NA: not approved and no data available for this age group; DPI: dry-powder
inhaler; AM: in morning; PM: in evening; US FDA: US Food and Drug Administration; MDI: metered-dose

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inhaler.

* Contains milk protein.

¶ Budesonide suspension is compatible with albuterol, ipratropium, and levalbuterol nebulizer solutions
in the same nebulizer. Use only jet nebulizers as ultrasonic nebulizers are ineffective for suspensions.

Δ Ciclesonide is not approved by the US FDA for use in children under 12. It is approved for use in
children 6 years of age and older in Canada, some European countries, and elsewhere.

◊ For fluticasone HFA, the low dose for children <4 years is higher than for children 5 to 11 years of age
due to lower dose delivered with facemask and data on efficacy in young children.

§ Contains lactose.

Data from:
1. National Heart, Blood, and Lung Institute Expert Panel Report 3 (EPR 3): Guidelines for the Diagnosis and Management of
Asthma. NIH Publication no. 08-4051, 2007.
2. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Updated 2012. Available at
www.ginasthma.org.

Graphic 68517 Version 18.0

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Stepwise asthma management in infants and children <4 years of age with
recurrent wheezing *

NAEPP ¶ GINA Our approach

(≤4 years old) (≤5 years old) (<4 years old

Therapy Therapy
Therapy
Asthma (all steps (all steps
Asthma symptoms (all steps include
symptoms/impact include SABA include SABA
SABA as needed)
as needed) as needed)

Intermittent: Step 1 Infrequent Step 1 Step 1

Daytime A short wheezing with viral Preferred: Preferred:
symptoms ≤2 course of infections and little
SABA as A short
days/week a daily ICS to no symptoms
needed course of a
No nocturnal beginning between illnesses
daily
at the Alternative:
awakenings medium-
start of a Short course
No dose ICS
respiratory of ICS at
interference beginning
tract onset of viral
with activities at the start
infection respiratory
Exacerbations of a
illness plus
treated with respiratory
SABA as
OCS ≤1/year tract
needed
infection
plus SABA
as needed

Alternative:
SABA as
needed

Mild persistent: Step 2 Asthma symptoms Step 2 Step 2

Daytime Preferred: that require SABA Preferred: Preferred:
symptoms >2 treatment >2
Daily low- Daily low- Daily low-
but <7 times/week on
dose ICS dose ICS dose ICS
days/week average for 1
Alternative: month or ≥3 Alternatives: Alternatives:
Nocturnal
awakenings 1 Daily LTRA exacerbations/year Daily LTRA Daily LTRA
to 2/month or or or
Minor Treated more Short course Intermitten
interference often than every 6 of ICS at low-dose
with activities to 8 weeks with onset of viral ICS used
Exacerbations SABA but asthma respiratory whenever a
treated with diagnosis is in illness SABA is
OCS ≥2 in 6 question Δ used

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months or ≥4
episodes of
wheezing
lasting more
than a day in a
year plus risk
factors for
persistent
asthma

Moderate persistent: Step 3 ◊ Asthma not well Step 3 § Step 3 §

Daily Daily low- controlled on low- Preferred: Preferred:
symptoms dose ICS- dose ICS
Double daily Daily low-
Nocturnal LABA
low-dose ICS dose ICS-
awakenings 3 or LABA
Alternative:
to 4/month
Daily low- or
Daily low-
Daily SABA use dose ICS
dose ICS plus Daily low-
Some activity plus LTRA
LTRA dose ICS
limitation or plus LTRA
Exacerbations
Daily Alternative:
treated with
medium-
OCS ≥2 in 6 Daily
dose ICS
months or ≥4 medium-
episodes of dose ICS
wheezing
lasting more
than a day in a
year plus risk
factors for
persistent
asthma

Severe persistent: Step 4 ◊ Asthma not well Step 4 § Step 4

Symptoms Preferred: controlled on Preferred: Preferred:
throughout the doubled low-dose
Daily Continue Daily
day ICS
medium- doubled daily medium-
Nocturnal dose ICS- low-dose ICS dose ICS-
awakenings LABA LABA
and
>1/week
Alternative: Refer to Alternative:
Need for SABA
Daily asthma Daily
several
medium- specialist for medium-
times/day
dose ICS evaluation dose ICS
Extreme
plus LTRA plus LTRA
limitation in Alternatives:
activity Add-on LTRA
or
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Exacerbations Increase
treated with frequency of
OCS ≥2 in 6 ICS dosing
months or ≥4 or
episodes of
Add
wheezing
intermittent
lasting more
ICS for
than a day in a
exacerbations
year plus risk
factors for
persistent
asthma

Step-up therapy Step 5 Step 5

for severe Preferred: Preferred:
asthma that is
Daily high- Daily high-
poorly controlled
dose ICS- dose ICS-
LABA LABA

Alternative: Alternative:
Daily high- Daily high-
dose ICS dose ICS
plus LTRA plus LTRA

Step 6 Step 6

Preferred: Preferred:
Daily high- Daily high-
dose ICS- dose ICS-
LABA plus LABA plus
OCS OCS

Alternative: Alternative:
Daily high- Daily high-
dose ICS dose ICS
plus LTRA plus LTRA
and OCS and OCS

Initial and step-up therapies are noted above. A higher level of initial therapy, with concurrent use of OCS
in some cases, may be chosen if the patient presents with an acute exacerbation. Treatment may be
stepped down if asthma is well controlled for at least 3 months and is stepped up 1 or 2 steps if asthma is
not well controlled or is very poorly controlled. An alternative to stepping up therapy is to first try one of
the alternative options in the same step. Before stepping up therapy, inhaler technique, adherence, and
exposure to potential triggers (eg, allergens, tobacco smoke exposures) should be assessed along with
evaluating for alternative and/or concomitant diagnoses.

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NAEPP: National Asthma Education and Prevention Program; GINA: Global Initiative for Asthma; SABA:
short-acting beta agonist; OCS: oral corticosteroid (glucocorticoid); ICS: inhaled corticosteroid
(glucocorticoid); LTRA: leukotriene receptor antagonist; LABA: long-acting beta agonist.

* Dosing is reviewed in other UpToDate topics and tables on the management of asthma in children.

¶ Theophylline, nedocromil, and cromolyn are not included in the table even though they were included
in NAEPP. They are rarely used due to the availability of more effective options.

Δ In these patients, a 3-month trial of therapy is reasonable and will help confirm or refute the diagnosis
of asthma.

◊ For children 4 years of age, refer to steps 3 and 4 in the UpToDate table for stepwise asthma
management in children aged 5 to 11.

§ Step-up therapy.

References:
1. National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. 2020 Focused
updates to the asthma management guidelines. National Heart, Lung, and Blood Institute, 2020. Available at:
https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-
guidelines (Accessed on December 16, 2020).
2. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Available at:
www.ginasthma.org (Accessed on October 27, 2022).

Graphic 127785 Version 7.0

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Stepwise asthma management in children 4 to 11 years old

Our approach
NAEPP* GINA
(4 to 11 years
(5 to 11 years old) (6 to 11 years old)
old)

Therapy
Asthma Asthma (all steps
Therapy Therapy
symptoms/impact symptoms include SABA
as needed)

Intermittent: Step 1 Infrequent Step 1 Step 1

Daytime SABA as asthma Preferred: Preferred:
symptoms ≤2 needed symptoms (eg,
Low-dose SABA as
days/week <2
ICS needed
Nocturnal times/month)
whenever
Alternatives:
awakenings SABA is
≤2/month Low-dose ICS
used
whenever
No
Alternatives: SABA used
interference
Daily low-
with activities
dose ICS
Normal FEV1
and FEV1/FVC
Exacerbations
≤1/year

Mild persistent: Step 2 ¶ Asthma Step 2 Step 2

Daytime Preferred: symptoms or Preferred: Preferred (includes
symptoms >2 need for SABA as needed):
Daily low- Daily low-
but <7 reliever inhaler
dose ICS and dose ICS Daily low-
days/week ≥2
SABA as dose ICS
times/month Alternatives:
Nocturnal needed
Daily LTRA Alternatives
awakenings 3
Alternative: or (includes SABA as
to 4/month
Daily LTRA needed):
Minor Low-dose
and SABA as Daily LTRA
interference ICS
needed or
with activities whenever
Normal FEV1 SABA is Low-dose ICS
and FEV1/FVC used whenever
Exacerbations SABA used
≥2/year

Moderate persistent: Step 3 ¶ Troublesome Step 3 Step 3

Preferred: asthma Preferred: Preferred:

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Daily Daily and as symptoms Daily low- Daily and as-

symptoms needed low- most days dose ICS- needed low-
Nocturnal dose ICS- or LABA dose ICS-
awakenings formoterol Waking due to or formoterol
>1/week but asthma ≥1 (fast-onset
Alternative: Daily
not daily time/month LABA)
Daily medium-
Daily SABA use (also assess Alternatives
medium-dose dose ICS
Some activity risk factors for (includes SABA as
ICS and as
exacerbations) Alternative:
limitation needed SABA needed):
Daily low-
FEV1 60 to 80% or Daily low-
dose ICS
predicted; dose ICS-
Daily low- plus LTRA
FEV1/FVC below LABA (slower-
dose ICS-
normal onset LABA)
LABA or low-
Exacerbations or
dose ICS plus
≥2/year
LTRA and as Daily
needed SABA medium-dose
ICS
or

Daily low-
dose ICS plus
LTRA

Severe persistent: Step 4 ¶ Severe asthma Step 4 ¶ Step 4

Symptoms Preferred: Preferred: Preferred:
throughout the
Daily and as Daily Daily and as
day
needed medium- needed
Nocturnal medium-dose dose ICS- medium-dose
awakenings ICS- LABA ICS-
most nights formoterol formoterol
or
Need for SABA (fast-onset
Alternative: Daily low-
several LABA)
Daily dose ICS
times/day
medium-dose plus LTRA Alternatives
Extreme
ICS-LABA and (includes SABA as
limitation in Alternatives:
as needed needed):
activity Daily
SABA Daily
FEV1 <60% medium-
or medium-dose
predicted; dose ICS-
ICS-LABA
FEV1/FVC below Daily LABA and
(slower- onse
normal medium-dose add-on
LABA)
Exacerbations ICS plus LTRA tiotropium
or
≥2/year and as or LTRA
needed SABA Daily high-
dose ICS
or

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Daily
medium-dose
ICS plus LTRA
or

Daily
medium-dose
ICS-LABA and
add-on
tiotropium or
LTRA

Step-up therapy Step 5 Step-up Step 5 Step 5

for severe Preferred: therapy for Preferred: Preferred (includes
asthma that is severe asthma SABA as needed):
Daily high- Daily
poorly controlled that is poorly
dose ICS- medium- Daily
controlled
LABA and as dose ICS- medium-dose
needed SABA LABA and ICS-LABA and
assess for tiotropium (in
Alternative:
possible children ≥6
Daily high-
high-dose years of age)
dose ICS plus
ICS-LABA or or
LTRA and as
add-on
needed SABA Daily high-
therapy
dose ICS-
Add-on therapy: (anti-IgE or
LABA (in
A biologic anti-IL4R)
children 4 to
agent (eg,
Alternative add- <6 years of
omalizumab,
on therapies: age)
mepolizumab)
Anti-IL-5R;
is an Alternatives
low-dose
additional (includes SABA as
OCS only as
option for needed):
last resort
patients ≥6 Daily
years of age medium-dose
ICS-LABA and
LTRA
or

Daily high-
dose ICS-
LABA
or

Daily high-
dose ICS plus
LTRA

Add-on therapy:

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A biologic
agent (eg,
omalizumab
[anti-IgE],
dupilumab
[anti-IL-4R], o
mepolizumab
[anti-IL-5R]) is
an additional
option for
patients ≥6
years of age

Step 6 Step 6

Preferred: One of the

above option
Daily high-
plus OCS
dose ICS-
LABA plus A biologic
OCS and as agent (eg,
needed SABA omalizumab,
dupilumab, o
Alternative:
mepolizumab
Daily high- is an
dose ICS plus additional
LTRA and OCS option for
and as patients ≥6
needed SABA years of age
Add-on therapy:
A biologic
agent (eg,
omalizumab,
mepolizumab)
is an
additional
option for
patients ≥6
years of age

Initial therapies are noted above. A higher level of initial therapy, with concurrent use of OCS in some
cases, may be chosen if the patient presents with an acute exacerbation. Treatment may be stepped
down if asthma is well controlled for at least 3 months and is stepped up 1 or 2 steps if asthma is not well
controlled or is very poorly controlled.

NAEPP: National Asthma Education and Prevention Program; GINA: Global Initiative for Asthma; SABA:
short-acting beta agonist; FEV1: forced expiratory volume in 1 second; FVC: forced vital capacity; ICS:

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inhaled corticosteroid (glucocorticoid); LTRA: leukotriene receptor antagonist; LABA: long-acting beta
agonist; OCS: oral corticosteroid (glucocorticoid); IgE: immunoglobulin E; IL-5R: interleukin 5 receptor.

* Theophylline, cromolyn, and nedocromil were not included in table even though they were included in
NAEPP. They are rarely used due availability of more effective options.

¶ Subcutaneous allergen immunotherapy is suggested as adjunctive treatment in patients with well-

controlled asthma and environmental allergies.

References:
1. National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. 2020 Focused
updates to the asthma management guidelines. National Heart, Lung, and Blood Institute, 2007. Available at:
https://www.nhlbi.nih.gov/health-topics/all-publications-and-resources/2020-focused-updates-asthma-management-
guidelines (Accessed on December 16, 2020).
2. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention. Available at:
www.ginasthma.org (Accessed on October 27, 2022).

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Contributor Disclosures
Gregory Sawicki, MD, MPH Consultant/Advisory Boards: Gilead [Cystic fibrosis]; Vertex [Cystic fibrosis].
All of the relevant financial relationships listed have been mitigated. Kenan Haver, MD No relevant
financial relationship(s) with ineligible companies to disclose. Robert A Wood, MD Grant/Research/Clinical
Trial Support: Aimmune [Food allergy]; ALK [Food allergy]; DBV Technologies [Food allergy]; FARE [Food
allergy]; Genentech [Food allergy]; NIAID [Food allergy]; Novartis [Food allergy]; Regeneron [Food allergy];
Siolta [Food allergy]. Consultant/Advisory Boards: Aravax [Food allergy]. All of the relevant financial
relationships listed have been mitigated. Gregory Redding, MD No relevant financial relationship(s) with
ineligible companies to disclose. Elizabeth TePas, MD, MS No relevant financial relationship(s) with
ineligible companies to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must
conform to UpToDate standards of evidence.

Conflict of interest policy

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