Preferred Intermittent asthma Persistent asthma: Daily medication Consult with asthma specialist if Step 3 care or higher is required. The stepwise approach is meant to assist, not Consider consultation at Step 2.Intermittent Asthma Persistent Asthma: Daily Medication Consult with asthma specialist if Step 4 care or higher is required. Consider consultation at Step 3. Alternative Alternative Quick-Relief Medication Quick-Relief Medication SABA PRN Low-dose ICS Cromolyn or Montelukast Cromolyn LTRA Nedocromil, or Theophylline Medium-dose ICS Medium-dose ICS + LABA or Montelukast High-dose ICS + LABA or Montelukast High-dose ICS LABA orMontelukast+ +Oral corticosteroids ICS Preferred SABA PRN Low-dose ICS Low-dose ICS Medium-dose ICS + + + LABALABA, LTRA, or Theophylline High-dose ICS + LABA High-dose ICS LABA + + Oral corticosteroids Oral corticosteroids Children 0–4 years of ageChildren 5–11 Years of Age Each Step: Patient Education and Environmental Control Each Step: Patient Education and Environmental Control, and Management of Comorbidities Steps 2–4:  Consider subcutaneous allergen immunotherapy for patients                   who have persistent, allergic asthma.  SABA as needed for symptoms. Intensity of treatment depends on severity of  symptoms.  With viral respiratory symptoms: SABA q 4–6 hours up to 24 hours (longer with  physician consult). Consider short course of oral systemic corticosteroids if exacerbation is severe or patient has history of previous severe exacerbations. Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations on initiating daily long-term-control therapy. Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB) generally indicates inadequate control and the need to step up treatment. OR Medium-dose ICS Medium-dose ICS LTRA or Theophylline + High-dose ICS LTRA or Theophylline + + High-dose ICSLTRA or Theophylline  SABA as needed for symptoms. Intensity of treatment depends on severity of  symptoms: up to 3 treatments at 20-minute intervals as needed. Short course of  oral systemic corticosteroids may be needed.   replace, the clinical decision making required to   meet individual patient needs.  If an alternative treatment is used and response is  inadequate, discontinue it and use the preferred  treatment before stepping up.  If clear benefit is not observed within 4–6 weeks,   and patient’s/family’s medication technique and   adherence are satisfactory, consider adjusting   therapy or an alternative diagnosis.  Studies on children 0–4 years of age are limited.  Step 2 preferred therapy is based on Evidence A. All other recommendations are based on expert opinion and extrapolation from studies in older children.  Clinicians who administer immunotherapy should be prepared and equipped to identify and treat  anaphylaxis that may occur. Key: Alphabetical listing is used when more than one treatment option is listed within either preferred or alternative therapy. ICS, Inhaled corti-costeroid; LABA, inhaled long-acting beta2-agonist; LTRA, leukotriene receptor antagonist, oral corti-costeroids, oral systemic corticosteroids; SABA, inhaled short-acting beta2-agonist  The stepwise approach is meant to assist, not  replace, the clinical decision making required to  meet individual patient needs.  If an alternative treatment is used and response is  inadequate, discontinue it and use the preferred  treatment before stepping up.  Theophylline is a less desirable alternative due to  the need to monitor serum concentration levels. Steps 1 and 2 medications are based on Evidence A.   Step 3 ICS and ICS plus adjunctive therapy are  based on Evidence B for efficacy of each treatment and extrapolation from comparator trials in older   children and adults–comparator trials are not available for this age group; Steps 4–6 are based on expert opinion and extrapolation from studies in   older children and adults.  Immunotherapy for Steps 2–4 is based on Evidence  B for house-dust mites, animal danders, and pollens;  evidence is weak or lacking for molds and cock roaches. Evidence is strongest for immunotherapy  with single allergens. The role of allergy in asthma is  greater in children than adults. Clinicians who administer immunotherapy should be prepared and equipped to identify and treat  anaphylaxis that may occur. Key: Alphabetical listing is used when more than one treatment option is listed within either preferred or alternative therapy. ICS, Inhaled corti-costeroid; LABA, inhaled long-acting beta2-agonist; LTRA, leukotriene receptor antagonist; SABA, inhaled short-acting beta2-agonist