Treatment of asthma in young children: evidence-based recommendations

Abstract

In the present review, we focus on evidence-based data for the use of inhaled corticosteroids (ICS), leukotriene receptor antagonist (LTRA), long-acting beta2-agonits (LABA) and oral corticosteroids (OCS), with a special emphasis on well-performed randomized clinical trials (RCTs) and meta-analyses of such trials for the chronic management of asthma/wheeze in infants and preschoolers. Results: Seven meta-analyses and 14 RCTs were reviewed. Daily ICS should be the preferred drug for infants/preschoolers with recurrent wheezing, especially in asthmatics. For those with moderate or severe episodes of EVW, the use of high intermittent ICS doses significantly reduce the use of OCS. There is no evidence of effect of intermittent ICS at low-moderate dose in preschoolers with mild EVW episodes. In preschoolers with asthma, there were no significant differences between daily vs. intermittent ICS in terms of asthma exacerbations with insufficient power to conclude to equivalence; however, for other asthma control outcomes, daily ICS works significantly better than intermittent ICS for older children. Daily ICS is superior to daily or intermittent LRTA for reducing symptoms, preventing exacerbations, and improving lung function. No RCTs testing combination therapy with ICS and LABA (or LTRA) were published in infant/preschoolers. Parent-initiation of OCS at the first sign of symptoms is not effective in children with recurrent wheezing episode. In terms of ICS safety, growth suppression is dose and molecule-dependent but it’s effect is not cumulative beyond the first year of therapy and may be associated with some catch-up growth while on or off therapy. Linear growth must be monitored as individual susceptibility to ICS drugs may vary considerably.

Preventing Exacerbations in Preschoolers With Recurrent Wheeze: A Meta-analysis

“…45 In 2015, Ducharme et al 13 published a nonsystematic review of preschool wheeze with meta-analyses of newer studies; they reported similar results comparing daily ICS with placebo (relative risk 0.57; 95% CI, 0.40-0.80) and daily and intermittent ICS (relative risk 0.91; 95% CI, 0.71-1.18). The conclusions of a 2016 nonsystematic review by CastroRodriguez et al 46 were also in line with our findings.…”

Daily inhaled corticosteroids or montelukast for preschoolers with asthma or recurrent wheezing: A systematic review

“…Therefore, additional studies at a low‐risk of bias are clearly warranted to compare the efficacy of ICS versus montelukast in preschoolers with asthma or recurrent wheezing. Parallel‐group trials with standardized reporting of outcomes would allow better quantification of the magnitude of effect for various efficacy and safety outcomes and more cross‐over trials are needed to establish solid evidence‐based criteria on which to personalize the initial choice of monotherapy . It is particularly crucial to establish the best controller therapy in this young age group as asthmatic preschoolers have the highest morbidity, experiencing more exacerbations requiring SC and hospital admissions than other all other pediatric age groups, with many exhibiting irreversible lung function impairment by 6 years of age .…”

Asma en la infancia: controversias que conllevan al subdiagnóstico

“…Un metaanálisis reciente evidenció que la terapia con CI inhalados debe preferirse sobre otros medicamentos (antagonistas de los leucotrienos, β-adrenérgicos de acción prolongada y corticoides orales) y que su utilización diaria es mejor que la intermitente para disminuir los síntomas respiratorios cotidianos (50).…”