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Asthma in the preschool age group consists of heterogeneous phenotypes, which may exhibit differential responses to treatment approaches.
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A severe intermittent wheeze phenotype is commonly seen in the preschool population.
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A variety of treatment strategies have been demonstrated to decrease severe episodes in the severe intermittent wheeze phenotype.
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Preschool children with persistent asthma with evidence of aeroallergen sensitization and/or peripheral blood eosinophilia should be started on daily
Management of Asthma in the Preschool Child
Section snippets
Key points
Children with evidence of atopy or allergic sensitization
Several phenotypic characterizations relating to atopy and allergic sensitization have been found to be associated with differences in response to asthma therapies in this age group. The first, and most widely used, is the Asthma Predictive Index, particularly the modified version (mAPI).5, 6 This index is used for children during the first 3 years of life to help predict the likelihood of persistent asthma at age 6 years, increasing the posttest probability to 90% in a high-risk cohort.7 The
Oral Corticosteroids
OCS are frequently prescribed for acute severe exacerbations in this age group, although there is limited evidence for consistent efficacy in this age group, and this efficacy seems to be related to severity of episode and site of care. Several studies in the preschool population have reported that OCS use in the ED setting was associated with decreased symptoms and length of hospital stay.46, 47, 48 A multicenter trial of children ages 1 to 17 years with moderate or severe asthma receiving OCS
Provider Related
Other differential diagnoses can masquerade as asthma in this age group and need to remain under consideration. These diagnoses include bronchiolitis, structural abnormalities such as right-sided aortic arch or vascular sling, chronic lung disease, foreign body disease, and cystic fibrosis, and are reviewed elsewhere.58
Barriers to Adherence
There are multiple potential barriers to treatment adherence in this age group, which should be considered when monitoring a preschool child with uncontrolled asthma symptoms.
Summary and future directions
Preschool asthma is a heterogeneous condition that can change over time. Recent studies have begun to crystallize evidence-based and phenotype-directed approaches for the young child with recurrent wheezing and asthma and can help predict treatment response. Clinical judgment and regular reevaluation remain essential in devising an optimal individualized treatment plan for each patient.
More research is needed to better understand the therapeutic options beyond step 2 GINA recommendations in
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Cited by (2)
The Use of Bacterial Lysate for the Prevention of Wheezing Episodes in Preschool Children: A Cost-Utility Analysis
2023, Journal of Allergy and Clinical Immunology: In PracticeCitation Excerpt :This fact causes most affected children to have minimal or no symptoms in periods between the wheezing episodes.4 This pattern of symptoms causes it to be challenging to manage these patients, because daily therapy with inhaled corticosteroids (ICSs) and other current treatment options for older children with persistent asthma are typically less effective in reducing respiratory morbidity in preschool children.1,8 In considering other therapeutic options, increasing recent evidence has shown the efficacy of bacterial lysate therapy for the prevention of wheezing episodes and asthma exacerbations in pediatric patients.9
Diagnosis and management of asthma in infants and preschoolers
2022, Clinical and Experimental Pediatrics
Disclosure Statement: C.G. Kwong: No financial or commercial interests to disclose. L.B. Bacharier: Dr Bacharier reports grants from NIH; personal fees from GlaxoSmithKline, Genentech/Novartis, Merck, DBV Technologies, Teva, Boehringer Ingelheim, AstraZeneca, WebMD/Medscape, Sanofi/Regeneron, Vectura, and Circassia.