Management of chronic asthma in childrens

Adult and child over 5 years	Child under 5 years
Step 1: occasional relief broncodilator Inhaled short-acting beta2 agonist as required (up to once daily) Note:Move to step 2 if needed more than twice a week, or if night-time symptoms more than once a week, or if exacerbation in the last 2 years requiring systemic corticosteroid or nebulised bronchodilator.	Step 1: occasional relief bronchodilator Short-acting beta2 agonist as required (not more than once daily) Note Preferably by inhalation (less effective and more side-effects when given by mouth) Move to step 2 if needed more than twice a week, or if night-time symptoms more than once a week, or if exacerbation in the last 2 years
Step 2: regular inhaled preventer therapy Inhaled short-acting beta2 agonist as required plus Regular standard-dose inhaled corticosteroid (alternative are considerably less effective)	Step 2: regular preventer therapy Inhaled short-acting beta2 agonist as required plus Either regular standard-dose  inhaled corticosteroid Or (if inhaled corticosteroid cannot be used) leukotriene receptor antagonist
Step 3: inhaled corticosteroid + long-acting inhaled beta2 agonist Inhaled short-acting beta2 agonist as required plus Regular standard-dose inhaled corticosteroid plus Regular inhaled long-acting beta2 agonist (salmeterol or formoterol) If asthma not controlled Increase dose of inhaled corticosteroid to upper end of standard dose range and Either stop long-acting beta2 agonist if of no benefit Or continue long-acting beta2 agonist if of some benefit If asthma still not controlled and long-acting beta2 agonist stopped, add one of Leukotriene receptor antagonist Modified-release oral theophylline Modified-release oral beta2 agonist	Step 3: add-on therapy Child under 2 years: Refer to respiratory paediatrician Child 2–5 years: Inhaled short-acting beta2 agonist as required plus Regular inhaled corticosteroid in standard dose plus Leukotriene receptor antagonist
	Step 4: persistent poor control Refer to respiratory paediatrician Stepping down Regularly review need for treatment
Step 4: high-dose inhaled corticosteroid + regular bronchodilators Inhaled short-acting beta2 agonist as required with Regular high-dose inhaled corticosteroid plus Inhaled long-acting beta2 agonist plus In adults 6-week sequential therapeutic trial of one or more of ·         Leukotriene receptor antagonist ·         Modified-release oral theophylline ·         Modified-release oral beta2 agonist Step 5: regular corticosteroid tablets Inhaled short-acting beta2 agonist as required with Regular high-dose inhaled corticosteroid and One or more long-acting bronchodilators (see step 4) plus Regular prednisolone tablets (as single daily dose) Note:In addition to regular prednisolone, continue high-dose inhaled corticosteroid (in exceptional cases may exceed licensed doses); these patients should normally be referred to an asthma clinic.	Standard-dose inhaled corticosteroids (given through a metered-dose inhaler and in children a large-volume spacer): Beclometasone dipropionate or budesonide 100–400 micrograms twice daily; child under 12 years 100–200 micrograms twice daily Fluticasone propionate 50–200 micrograms twice daily; child 4–12 years 50–100 micrograms twice daily Mometasone furoate (given through a dry-powder inhaler) 200 micrograms twice daily, Alternatives to inhaled corticosteroid are leukotriene receptor antagonists, theophylline, inhaled cromoglicate, or inhaled nedocromil. High-dose inhaled corticosteroids (given through a metered-dose inhaler and a large-volume spacer): Beclometasone dipropionate or budesonide 0.4–1 mg twice daily; child 5–12 years 200–400 micrograms twice daily Fluticasone propionate 200–500 micrograms twice daily; child 5–12 years 100–200 micrograms twice daily. Mometasone furoate (given through a dry powder inhaler) 200–400 micrograms twice daily. Note. Doses of inhaled corticosteroids here are for CFC-containing metered-dose inhalers; dose adjustments may be required for other inhaler devices. Failure to achieve control with these doses is unusual.Lung-function measurements cannot be used to guide management in those under 5 years