STEPwise Treatment of Asthma for Infants and Children < 5 yo

Classify Severity: Clinical Features Before Treatment or Adequate Control Medications Required to Maintain Long-Term Control

Daily Medications
Mild Intermittent
<= 2 days/week

<= 2 nights/week
  • No daily medication needed
Mild Persistent
> 2/week but < 1x/day

> 2 nights/month
  • Preferred treatment:
    • Low-dose inhaled corticosteroids (with nebulizer or MDI with holding chamber with or without face mask or DPI).
  • Alternative treatment (listed alphabetically)
    • Cromolyn (nebulizer is preferred or MDI with holding chamber) OR leukotriene receptor antagonist
Moderate Persistent

> 1 night/week
  • Preferred treatments:
    • Low-dose inhaled corticosteroids and long-acting beta2-agonists


    • Medium-dose inhaled corticosteroids
  • Alternative treatment:
    • Low-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline

If needed (particularly in patients with recurring severe exacerbations):

  • Preferred treatment:
    • Medium-dose inhaled corticosteroids and long-acting beta2-agonists.
  • Alternative treatment:
    • Medium-dose inhaled corticosteroids and either leukotriene receptor antagonist or theophylline
Severe Persistent

  • Preferred treatment:
    • High-dose corticosteroids


    • Long-acting inhaled beta2-agonists

    AND , if needed,

    • Corticosteroid tablets or syrup long term (2 mg/kg/day, generally do not exceed 60 mg per day) (Make repeat attempts to reduce systemic corticosteroids and maintain control with high-dose inhaled corticosteroids.)

National Asthma Education and Prevention Program Expert Panel Report 2:  Guidelines for the Diagnosis and Management of Asthma


Quick Relief

All Patients

  • Bronchodilator as needed for symptoms. Intensity of treatment will depend upon severity of exacerbations.
    • Preferred treatment: Short-acting inhaled beta2-agonists by nebulizer or face mask and space/holding chamber
    • Alternative treatment: Oral beta2-agonist
  • With viral respiratory infection
    • Bronchodilator q 4-6 hours up to 24 hours (longer with physician consult); in general, repeat no more than once every 6 weeks
    • Consider systemic corticosteroid if exacerbation is severe or patient has history of previous severe exacerbations
  • Use of short-acting beta2-agonists > 2 times a week in intermittent asthma (daily, or increasing use in persistent asthma) may indicate the need to initiate (increase) long-term control therapy
Step Down:
    Review treatment every 1 to 6 months; a gradual stepwise reduction in treatment may be possible.


  • The stepwise approach is intended to assist, not replace, the clinical decisionmaking required to meet individual patient needs.
  • Classify severity: assign patient to most severe step in which any feature occurs
  • There are very few studies on asthma therapy for infants
  • Gain control as quickly as possible (a course of short systemic corticosteroids may be required); then step down to the least medication necessary to maintain control
  • Provide parent education on asthma management and controlling environmental factors that make asthma worse (e.g. allergies and irritants)
  • Consultation with an asthma specialist is recommended for patients with moderate or severe persistent asthma. Consider consultation for patients with mild persistent asthma.
Step Up:
    If control is not achieved, consider step up.  First, review patient medication technique, adherence, and environmental control.

Goals of Therapy: Asthma Control

  • Minimal or no chronic symptoms day or night
  • Minimal or no exacerbations
  • No limitations on activities; no school/parent's work missed
  • Minimal use of short-acting inhaled beta2-agonist (< 1x per day, < 1 canister/month)
  • Minimal or no side effects from medications