Practice-Changing Updates for Pediatric Patients with Asthma

Angela Marko, DO, University Hospitals Rainbow Babies & Children’s
Eva Johnson, MD, FAAP, University Hospitals Rainbow Babies & Children’s
William Hardie, MD, Cincinnati Children’s Hospital Medical Center

In the United States, asthma is the most common chronic childhood lung disease and affects 6.5% of all children less than 18 years old1. Asthma guidelines play an important role in helping clinicians practice with the most up-to-date evidence-based recommendations for asthma management. The National Asthma Education and Prevention Program (NAEPP) published an Expert Panel Report in 2007 and since that time, significant progress has been made by scientists to further understand asthma pathophysiology, diagnosis, management, and treatment. Therefore, in 2020 an updated report from the NAEPP supported by the National Institutes of Health’s (NIH) National Heart, Lung, and Blood Institute (NHLBI) was published. While the guidelines addressed six key issues, the two most noteworthy and practice-changing updates are:

  1. Guidance on the use of intermittent ICS (inhaled corticosteroids) for children ages 0-4 years with recurrent viral wheezing2
  • Recommended for children who have had repeated wheezing triggered by apparent respiratory tract infections (≥3 wheezing episodes in lifetime, or ≥2 wheezing episodes in past year) AND are asymptomatic between respiratory tract infections. (This regimen is not recommended for individuals that are symptomatic between respiratory tract infections.)
  • Start a short course (7-10 days) of twice daily high dose ICS at the onset of a respiratory tract infection along with as-needed SABA (short-acting β-agonist (i.e., albuterol)) for quick-relief therapy.

Potential benefits with this regimen include reducing exacerbations requiring systemic corticosteroids, as well as allowing caregivers to initiate this intermittent ICS treatment at home without a visit to a health care provider. To use this regimen, caregivers must also be able to recognize symptoms of the respiratory tract infection early to initiate ICS treatment and have clear written instructions on how to initiate the action plan.

  1. Use of Single Maintenance and Reliever Therapy (“SMART”)2
  • In children ages 4 years and older, the preferred therapy for patients with moderate or severe (Step 3 or 4) persistent asthma is SMART, which uses a single-inhaler ICS and LABA (long-acting β-agonist) as the daily asthma maintenance AND as needed for quick-relief.
  • When using the SMART regimen, the ICS dose is low to medium and the LABA component must be formoterol as this has a rapid onset of action making it suitable for quick-relief therapy. Under this treatment regimen, ICS-formoterol is used both daily and as needed.

Potential benefits with this regimen include improved daily asthma control and quality of life, as well as reduced asthma exacerbations requiring a medical visit or systemic corticosteroids. This approach may also help simplify asthma regimens, making it easier for patients and caregivers to understand their treatment plan. There are several potential considerations with this approach that clinicians should be aware of:

  • ICS-formoterol should be administered as maintenance therapy twice daily and then one to two puffs as needed for asthma symptoms. The maximum number of puffs per day is 12 (54 mcg formoterol) for individuals ages 12 years and older and 8 puffs per day (36 mcg formoterol) for children ages 4–11 years. Clinicians should advise individuals with asthma or their caregivers to contact their physician if they need to use more than these amounts.
  • Not all insurers cover ICS-formoterol as the preferred inhaler preventing use of SMART in their insured patients.
  • A one-month supply of an ICS-formoterol medication may not last a month if the inhaler is used as prescribed for both daily and quick relief therapy. It is best to prescribe two canisters per month when using the SMART regimen.

SMART may not be necessary for patients that are already well controlled on alternative treatments, such as maintenance ICS-LABA with SABA as quick-relief therapy. However, patients whose asthma is uncontrolled on this regimen should be started on SMART, if possible, before stepping-up therapy.

While the current guideline changes often simplify asthma management for patients and caregivers, these changes represent a shift in current asthma treatment practices. It is crucial for clinicians to counsel both patients and families on their home-going medication regimen and supply an asthma action plan. The asthma action plan should clearly spell out steps to take in the event of worsening asthma symptoms (reflecting the new dosing considerations as discussed) and be reviewed at each asthma and well child visit.

Resources are available at: National Institutes of Health’s National Heart, Lung, and Blood Institute Digital Toolkit (2020)


  1. 2021 National Health Interview Survey (NHIS) Data | CDC. Accessed December 9, 2023.
  2. Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP, et al. 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group [published correction appears in J Allergy Clin Immunol. 2021 Apr;147(4):1528-1530]. J Allergy Clin Immunol. 2020;146(6):1217-1270. doi:10.1016/j.jaci.2020.10.003
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