Leukotrienes, synthesized via the arachidonic acid metabolism cascade, are potent mediators of inflammation and smooth
Viral upper Limit exposure to viral infections (day care respiratory tract with fewer children) (RSV, influenza virus) with persistent asthma Tobacco smoke, No smoking around the child or in child’s wood smoke home
Help parents and caregivers quit smoking Eliminate use of wood stoves and fireplaces Dust mites Essential actions
Encase pillow, mattress, and box spring in allergen-impermeable encasement Wash bedding in hot water weekly
Avoid sleeping or lying on upholstered furniture Minimize number of stuffed toys in child’s bedroom Reduce indoor humidity to <50% If possible, remove carpets from bedroom and play areas; if not possible, vacuum frequently Animal dander Remove the pet from the home or keep outdoors (if removal is not acceptable) Keep pet out of bedroom
Use a filter on air ducts in child’s room Wash pet weekly (the evidence to support this has not been firmly established)
Cockroach allergens Do not leave food or garbage exposed Use boric acid traps Reduce indoor humidity to <50% Fix leaky faucets, pipes
Indoor mold Avoid vaporizers Reduce indoor humidity to <50% Fix leaky faucets, pipes
From American Academy of Allergy Asthma & Immunology: Pediatric Asthma:
Promoting Best Practice, Milwaukee, Wisconsin, 1999, American Academy of
Allergy Asthma & Immunology, p 50. RSV, Respiratory syncytial virus.
muscle bronchoconstriction. Leukotriene modifiers are oral, daily-use medications that inhibit these biologic effects in the airway. Two classes of leukotriene modifiers include cysteinyl leukotriene receptor antagonists (zafirlukast and montelukast) and leukotriene synthesis inhibitors (zileuton). The leukotriene receptor antagonists have much wider appeal than zileuton. Zafirlukast is approved for children older than 5 years of age and is given twice daily. Montelukast is dosed once daily, at night, as 4-mg granules or chewable tablets (for children 6 months to 5 years), 5-mg chewable tablets (6 to 14 years), and 10-mg tablets (15 years of age or older). Pediatric studies show the usefulness of leukotriene modifiers in mild asthma and the attenuation of exercise-induced bronchoconstriction. These agents may be helpful as steroid-sparing agents in patients with asthma that is more difficult to control.
Long-Acting β2-Agonists Long-acting β2-agonists, formoterol and salmeterol, have twice-daily dosing and relax airway smooth muscle for 12 hours but do not have any significant anti-inflammatory effects. Adding a long-acting bronchodilator to inhaled corticosteroid therapy is more beneficial than doubling the dose of inhaled corticosteroids. Multiple formulations are available. Formoterol is approved for use in children older than 5 years of age for maintenance asthma therapy and for prevention of exercise-induced asthma. It has a rapid onset of action similar to albuterol (15 minutes). Salmeterol is approved for children 4 years of age or older and has an onset of 30 minutes. Because combination agents administer two medications simultaneously, compliance is generally improved.
Theophylline was more widely used previously, but, because current management is aimed at inflammatory control, its popularity has declined. It is mildly to moderately effective as a bronchodilator and is considered an alternative, add-on treatment to lowand medium-dose inhaled corticosteroids.