Asthma Step Up Therapy in Pediatrics

Asthma, a chronic respiratory condition characterized by airway inflammation and bronchial hyperresponsiveness, affects a significant number of pediatric patients worldwide. Managing asthma step up therapy in pediatrics plays a crucial role in optimizing treatment outcomes. Step-up therapy, also known as escalation therapy, involves adjusting medication regimens to achieve better symptom control and prevent exacerbations.

 This approach is particularly important when initial treatment strategies, such as reliever medications or low-dose inhaled corticosteroids, prove insufficient. In pediatric asthma management, step-up therapy is an essential component that helps healthcare providers tailor treatment plans to individual needs. 

This article aims to explore the asthma step up therapy in pediatrics, the available options for escalating treatment, relevant guidelines, factors influencing therapy decisions, assessment of treatment response, and future directions in this evolving field of asthma management.

Understanding Asthma Step-Up Therapy

Asthma step-up therapy is a vital component in the management of pediatric asthma, involving the adjustment of medication regimens to achieve better symptom control and prevent exacerbations. 

This proactive approach aims to optimize treatment outcomes for children with asthma by escalating the treatment plan when initial strategies prove insufficient.

Definition and Purpose of Step-Up Therapy

Step-up therapy, also known as escalation therapy, is the process of intensifying asthma treatment by increasing medication doses or adding additional medications. 

The primary purpose of step-up therapy is to improve asthma control, reduce symptoms, and prevent asthma attacks. 

By adjusting the treatment regimen, healthcare providers strive to achieve better lung function and quality of life for pediatric patients.

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Criteria for Initiating Step-Up Therapy

The decision to initiate step-up therapy in pediatric asthma patients is based on specific criteria. These criteria include:

  • Poor symptom control: When a child continues to experience frequent symptoms, such as wheezing, coughing, and shortness of breath, despite adhering to the current treatment plan.
  • Increased rescue medication use: If a child requires frequent use of short-acting bronchodilators (reliever medications) to alleviate symptoms, it may indicate the need for step-up therapy.
  • Exacerbations: Recurrent asthma exacerbations, characterized by severe symptoms or the need for systemic corticosteroids, may necessitate the escalation of treatment.
  • Decreased lung function: If pulmonary function tests reveal a decline in lung function or poor response to the current treatment, step-up therapy may be warranted.
asthma step up therapy pediatrics

Goals of Step-Up Therapy

The overarching goals of step-up therapy in pediatric asthma management are:

  • Improved symptom control: Step-up therapy aims to reduce the frequency and severity of asthma symptoms, allowing children to engage in regular activities without disruption.
  • Prevention of exacerbations: By adjusting the treatment plan, step-up therapy helps minimize the risk of asthma exacerbations and related complications.
  • Enhanced lung function: Optimizing lung function is a key objective of step-up therapy, ensuring that children have improved airflow and overall respiratory health.
  • Minimized medication side effects: Step-up therapy aims to strike a balance between effective treatment and minimizing the potential side effects associated with escalated medications.

Read More: Allergy Meds That Help With Asthma: Managing Asthma Symptoms Triggered by Allergies

Step-Up Therapy Options for Pediatric Asthma

When implementing step-up therapy in pediatric asthma management, healthcare providers have several options to consider. 

These treatment options, available in various forms, aim to alleviate symptoms, improve lung function, and enhance overall asthma control in children. The following are common step-up therapy options utilized in pediatric asthma:

Inhaler-Based Medications:

  • Short-Acting Bronchodilators: These medications, such as albuterol, provide quick relief by relaxing the airway muscles, allowing improved airflow during acute asthma episodes.
  • Inhaled Corticosteroids: These medications, such as fluticasone and budesonide, reduce airway inflammation and help prevent asthma symptoms. They are typically administered daily as a maintenance treatment.
  • Combination Inhalers: Some inhalers combine both a long-acting bronchodilator and an inhaled corticosteroid. These medications, such as fluticasone/salmeterol or budesonide/formoterol, offer a dual approach by providing both symptom relief and long-term control.

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Oral Medications:

  • Leukotriene Modifiers: These oral medications, such as montelukast, zafirlukast, or zileuton, target specific chemicals involved in the inflammatory response of asthma. They are typically used as an add-on therapy to inhaled corticosteroids.
  • Systemic Corticosteroids: In cases of severe exacerbations or uncontrolled asthma, short courses of oral corticosteroids, such as prednisone, may be prescribed to rapidly reduce airway inflammation and restore asthma control.
asthma step up therapy pediatrics

Step-Up Therapy Guidelines for Pediatric Asthma

Effective management of pediatric asthma requires adherence to established guidelines for step-up therapy. 

These guidelines provide healthcare providers with evidence-based recommendations for adjusting treatment regimens to optimize asthma control in children. The following are key aspects covered by step-up therapy guidelines:

Overview of Established Guidelines:

Guidelines, such as those developed by the Global Initiative for Asthma (GINA), the National Asthma Education and Prevention Program (NAEPP), or national pediatric respiratory societies, offer comprehensive recommendations for step-up therapy in pediatric asthma.

These guidelines provide a framework for healthcare providers to assess disease severity, determine treatment goals, and guide the selection of appropriate step-up therapy options.

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Age-Specific Considerations and Dosage Adjustments:

Step-up therapy guidelines recognize that the approach to asthma management may vary based on a child’s age. Infants, toddlers, school-age children, and adolescents may require different dosages or delivery methods for medications.

Dosage adjustments for inhaled corticosteroids or bronchodilators may be necessary to ensure appropriate efficacy and minimize side effects based on the child’s age, weight, and disease severity.

Monitoring and Reassessment:

Step-up therapy guidelines emphasize the importance of regular monitoring and reassessment to evaluate treatment response and determine the need for further step-up therapy.

Objective measures, such as peak flow measurements or spirometry, can provide quantifiable data on lung function, while subjective measures, including symptom diaries or validated questionnaires, help assess day-to-day symptoms and quality of life.

Following step-up therapy guidelines allows healthcare providers to make informed decisions regarding treatment escalation and adjustments. 

By considering age-specific factors, dosage adjustments, and regularly monitoring treatment response, healthcare professionals can optimize asthma control, minimize the risk of exacerbations, and improve the overall well-being of pediatric asthma patients. 

It is essential for healthcare providers to stay up-to-date with current guidelines and integrate them into clinical practice to ensure the best possible outcomes for children with asthma.

Factors Influencing Step-Up Therapy Decisions

When considering step-up therapy for pediatric asthma patients, healthcare providers must take into account various factors that influence treatment decisions. 

These factors play a crucial role in determining the appropriate escalation of asthma management. The following are key factors that influence step-up therapy decisions:

Disease Severity and Symptom Control:

The severity of asthma symptoms and the level of asthma control achieved with the current treatment plan are important factors in determining the need for step-up therapy.

If a child experiences persistent or worsening symptoms, despite adhering to the current treatment regimen, it may indicate the necessity for escalation.

Patient-Specific Factors:

  • Age: The age of the child can influence the selection of medications and the mode of administration. Younger children may have difficulty using inhalers effectively and may require alternative delivery systems.
  • Comorbidities: The presence of other medical conditions, such as allergies, rhinitis, or obesity, may impact asthma control and influence the choice of step-up therapy options.
  • Adherence: The child’s adherence to the current treatment plan is crucial. Poor adherence may result in ineffective symptom control and necessitate step-up therapy.

Environmental Triggers and Allergens:

Identifying and addressing environmental triggers, such as allergens (e.g., dust mites, pollen, pet dander), pollutants, or irritants, is essential in managing asthma. 

If exposure to triggers is contributing to poor asthma control, step-up therapy may be necessary.

Treatment Response and Potential Side Effects:

Healthcare providers must assess how the child responds to the current treatment plan. If there is an inadequate response or inadequate control of symptoms, step-up therapy may be warranted.

Additionally, consideration should be given to the potential side effects of medications. If the child experiences significant side effects from the current treatment, alternative step-up therapy options may be explored.

Assessing Treatment Response and Adjusting Step-Up Therapy

Assessing the response to treatment and making appropriate adjustments is a critical aspect of step-up therapy in pediatric asthma management. 

Regular evaluation ensures that the treatment plan remains effective in controlling symptoms and preventing exacerbations. 

The following subheadings highlight key considerations in assessing treatment response and adjusting step-up therapy:

Importance of Regular Follow-ups and Monitoring:

Regular follow-up appointments allow healthcare providers to assess treatment response, monitor symptom control, and evaluate the need for step-up therapy adjustments.

Follow-ups provide an opportunity to address any concerns, reinforce medication adherence, and educate patients and their families about asthma management.

asthma step up therapy pediatrics

Objective and Subjective Measures of Treatment Response:

  • Objective Measures: Objective measures include spirometry, peak flow measurements, or fractional exhaled nitric oxide (FeNO) levels. These tests provide quantitative data on lung function and airway inflammation, aiding in the assessment of treatment response and the need for step-up therapy.
  • Subjective Measures: Subjective measures involve patient-reported outcomes, such as symptom diaries or validated questionnaires (e.g., Asthma Control Test, Childhood Asthma Control Test). These tools help evaluate day-to-day symptoms, quality of life, and the impact of asthma on daily activities.

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Strategies for Adjusting Medication and Treatment Plans:

  • Step-Up Therapy Options: Based on the assessment of treatment response, healthcare providers may adjust the medication regimen by increasing the dose of inhaled corticosteroids, adding a long-acting bronchodilator, or considering alternative medications.
  • Combination Inhalers: If symptom control is suboptimal, healthcare providers may consider prescribing combination inhalers that provide both a long-acting bronchodilator and an inhaled corticosteroid in a single device.
  • Adherence and Education: Assessing medication adherence is crucial, as poor adherence can contribute to inadequate treatment response. Healthcare providers should ensure patients and their families understand the correct inhaler technique and the importance of consistent medication use.

Shared Decision-Making and Patient/Family Engagement:

  • Involving patients and their families in treatment decisions fosters a collaborative approach and promotes adherence to the step-up therapy plan.
  • Patient and family education, providing information about the rationale for step-up therapy, potential benefits, and addressing any concerns, can enhance treatment acceptance and engagement.
  • Regular assessment of treatment response, utilizing both objective and subjective measures, allows healthcare providers to make timely adjustments to step-up therapy. 

Challenges and Limitations of Step-Up Therapy in Pediatrics

Implementing step-up therapy in pediatric asthma management can present various challenges and limitations that healthcare providers need to address. 

Understanding these challenges is crucial for optimizing treatment outcomes and overcoming barriers to effective asthma control. 

The following subheadings explore the key challenges and limitations of step-up therapy in pediatrics:

Treatment Adherence:

Adherence to medication regimens can be a significant challenge, particularly in pediatric populations. 

Children may struggle with proper inhaler technique, forget to take medications, or resist treatment due to taste or inconvenience.

Poor treatment adherence can undermine the effectiveness of step-up therapy, leading to suboptimal asthma control and increased risk of exacerbations.

Patient/Family Education and Communication:

Limited understanding of asthma and its management among patients and their families can hinder the successful implementation of step-up therapy.

Language barriers, health literacy issues, or cultural beliefs can affect the comprehension and adherence to treatment plans, making effective communication and education essential.

Availability and Access to Medications:

Some regions or healthcare settings may have limitations in the availability or affordability of certain medications, which can impact the feasibility of step-up therapy.

Accessibility issues, such as distance to healthcare facilities or limited healthcare resources, can also hinder timely adjustments and monitoring of step-up therapy.

Side Effects and Safety Considerations:

Escalating medication regimens in step-up therapy can increase the risk of potential side effects associated with higher doses or additional medications.

Balancing the benefits of improved asthma control against the potential risks and side effects is an important consideration when implementing step-up therapy.

Individual Variability and Treatment Response:

Each child’s response to step-up therapy may vary, and finding the most effective treatment approach may require trial and error.

Some children may not respond adequately to certain medications or may require alternative treatment options, making treatment adjustment and individualization crucial.

Addressing these challenges and limitations requires a comprehensive approach. Healthcare providers can overcome these barriers by:

  • Providing clear and patient-centered education about asthma and step-up therapy.
  • Supporting treatment adherence through regular follow-ups, reminders, and adherence aids.
  • Collaborating with patients, families, and other healthcare professionals to develop individualized treatment plans.
  • Ensuring access to necessary medications and considering affordability and availability.

Future Directions and Emerging Therapies

The field of pediatric asthma management is constantly evolving, and ongoing research and advancements hold promise for future improvements in step-up therapy. 

Emerging therapies and innovative approaches are being explored to enhance treatment outcomes and address the specific needs of pediatric patients. 

The following subheadings discuss some future directions and emerging therapies in the management of pediatric asthma:

Personalized Medicine and Biomarkers:

Advancements in understanding asthma phenotypes and endotypes are paving the way for personalized medicine approaches. 

Biomarkers, such as blood eosinophil count, FeNO levels, or genetic markers, may help identify patients who are more likely to benefit from specific therapies.

Tailoring step-up therapy based on individual characteristics and biomarkers can optimize treatment response and minimize the risk of adverse effects.

Biologic Therapies:

Biologic therapies specifically targeting key molecules and pathways involved in asthma pathogenesis are showing promise in both adult and pediatric populations.

Monoclonal antibodies, such as omalizumab, mepolizumab, and dupilumab, target specific immune pathways and have demonstrated efficacy in reducing exacerbations and improving asthma control in severe asthma. 

Further studies are underway to evaluate their efficacy and safety in pediatric patients.

Novel Inhaler Technologies:

Advancements in inhaler technologies aim to improve drug delivery and enhance patient adherence. Inhalers with built-in sensors and digital monitoring capabilities can provide real-time feedback on inhalation technique and medication usage.

Smart inhalers, connected to mobile applications, can help track adherence, provide reminders, and facilitate communication between patients and healthcare providers.

Environmental Interventions:

Addressing environmental triggers plays a vital role in asthma management. Future directions include the development of innovative interventions to reduce exposure to allergens, air pollutants, and irritants in home and school environments.

Strategies such as air purifiers, allergen-specific immunotherapy, and asthma-friendly housing design are being explored to minimize the impact of environmental factors on asthma control.

Telemedicine and Digital Health:

Telemedicine and digital health platforms have gained momentum, particularly in light of the COVID-19 pandemic. These technologies provide opportunities for remote monitoring, virtual consultations, and improved patient engagement in asthma management.

Remote monitoring devices, wearable sensors, and mobile applications can enable real-time tracking of symptoms, lung function, and adherence, facilitating early detection of treatment response and the need for step-up therapy adjustments.


Effective step-up therapy is essential for optimizing asthma control in pediatric patients. By following established guidelines, considering individual patient factors, regularly assessing treatment responses, and adjusting therapy as needed, healthcare providers can improve asthma outcomes and enhance the quality of life for children with asthma. 

However, challenges such as treatment adherence, patient education, medication availability, and individual variability must be addressed to ensure the successful implementation of step-up therapy. 

Future directions and emerging therapies, including personalized medicine, biologic therapies, novel inhaler technologies, environmental interventions, and telemedicine, hold promise for further advancements in pediatric asthma management. 

By embracing these innovations and staying up-to-date with current research, healthcare providers can continue to enhance step-up therapy strategies and improve long-term outcomes for pediatric asthma patients.


What is step-up therapy in pediatric asthma?

Step-up therapy refers to the adjustment or escalation of treatment regimens in pediatric asthma management to achieve better control of symptoms and reduce the risk of exacerbations.

When is step-up therapy recommended for pediatric asthma?

Step-up therapy may be recommended when a child’s asthma symptoms are not adequately controlled with the current treatment plan or when there is a need to prevent worsening of symptoms or exacerbations.

How is treatment response assessed in pediatric asthma?

Treatment response in pediatric asthma can be assessed through objective measures such as spirometry, peak flow measurements, and subjective measures such as symptom diaries and validated questionnaires.

What are the challenges of step-up therapy in pediatric asthma?

Challenges of step-up therapy in pediatric asthma include treatment adherence, patient education and communication, medication availability, potential side effects, and individual variability in treatment response.

What are the future directions in pediatric asthma management?

Future directions in pediatric asthma management include personalized medicine, biologic therapies, novel inhaler technologies, environmental interventions, and the use of telemedicine and digital health platforms.

What are biologic therapies in pediatric asthma?

Biologic therapies are targeted treatments that specifically block key molecules or pathways involved in asthma. They have shown efficacy in reducing exacerbations and improving asthma control in severe cases.

How can telemedicine and digital health aid in step-up therapy for pediatric asthma?

Telemedicine and digital health platforms enable remote monitoring, virtual consultations, and improved patient engagement in asthma management. They facilitate real-time tracking of symptoms, lung function, and adherence, aiding in the early detection of treatment response and the need for step-up therapy adjustments.

How can environmental interventions help in pediatric asthma management?

Environmental interventions focus on reducing exposure to allergens, air pollutants, and irritants in the home and school environments. They can help minimize triggers and improve asthma control.

Why is individualization important in step-up therapy for pediatric asthma?

Individualization is important in step-up therapy as each child may respond differently to treatments. Tailoring therapy based on individual factors and treatment response improves the chances of achieving optimal asthma control.

Medical References

  • Global Initiative for Asthma (GINA). (2021). Global strategy for asthma management and prevention.
  • National Asthma Education and Prevention Program (NAEPP). (2020). Expert panel report 3: Guidelines for the diagnosis and management of asthma.
  • Zeiger, R. S. (2020). Step-up therapy for children with uncontrolled asthma receiving inhaled corticosteroids. Journal of Allergy and Clinical Immunology: In Practice, 8(7), 2165-2173.
  • Fitzpatrick, A. M., & Bacharier, L. B. (2020). Biologic therapy for the treatment of asthma in children and adolescents. Journal of Allergy and Clinical Immunology: In Practice, 8(7), 2148-2156.
  • Pijnenburg, M. W., et al. (2021). Monitoring asthma in children. European Respiratory Journal, 58(2), 2003093.
  • Portnoy, J. M., et al. (2020). Environmental assessment and exposure reduction of pests and allergens: A practice parameter. Annals of Allergy, Asthma & Immunology, 124(1), 28-47.

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