Asthma in Children Aged 6–11 Years: What to Do When Step 4 Treatment Has Not Achieved Control
Clinical Scenario
This protocol addresses children aged 6 to 11 years who have asthma and have not reached adequate control despite Step 4 therapy. Children in this age group require ICS-containing treatment at every step; management with a short-acting reliever alone is not appropriate at this stage of care.
Step 4 Did Not Achieve the Treatment Goals
The child has been managed on Step 4 — a medium-dose ICS-LABA regimen or a low-dose ICS-formoterol maintenance-and-reliever approach, with referral to a pediatric asthma expert — yet the goals of well-controlled asthma have not been met: no troublesome symptoms during the day or night, no severe exacerbations, normal or near-normal lung function, and the ability to lead a fully active life.
Next Step: Severe Asthma — Step 5
At Step 5, management shifts toward phenotypic assessment — identifying the underlying airway inflammation profile — followed by consideration of targeted add-on therapy. The protocol covers both bronchodilatory and biologic add-on options; the appropriate selection depends on the individual child's phenotype and is set out in the full structured regimen.
References
- Children aged 6–11 years with asthma should not be treated with SABA alone; they should all receive ICS-containing treatment.
- Tiotropium can be added to other recommended treatments.
- Anti-immunoglobin E (subcutaneous omalizumab) for severe allergic asthma.
- Anti-interleukin 5 (subcutaneous mepolizumab) for severe eosinophilic asthma.
- Anti-interleukin 4 receptor alpha (subcutaneous dupilumab) for severe eosinophilic asthma/asthma with Type 2 airway inflammation.
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