Inhaled corticosteroids are the preferred initial long-term control therapy for children of all ages (Fig. 78-3). Daily longterm control therapy is recommended for infants and young children 0 to 4 years of age who had four or more episodes of wheezing in the previous year that lasted more than 1 day, affected sleep, and who have a positive asthma predictive index. For children over 5 years of age with moderate persistent asthma, combining long-acting bronchodilators with low-tomedium doses of inhaled corticosteroids improves lung function and reduces rescue medication use. For children with severe persistent asthma, a high-dose inhaled corticosteroid and a long-acting bronchodilator are the preferred therapy. The guidelines also recommend that treatment be reevaluated within 2 to 6 weeks of initiating therapy. Once asthma is under control, control should be assessed on an ongoing basis every 1 to 6 months. The asthma should be well controlled for at least 3 months before stepping down therapy. Note that asthma management guidelines are based on review of the published evidence, not solely on age recommendations and dosages approved by the U.S. Food and Drug Administration.
Step up if needed (first check inhaler technique, adherence, environmental control, and comorbid conditions)
Step down if possible (and asthma is well controlled at least 3 months)