RE: A Pulmicort Flexhaler prescribed for my 4 1/2 year old son

[Jennymom]

Hello :-).  My son has asthma which manifests itself in a cough and often shows up during/after colds (he doesn't appear to have any problems with breathing in enough air... no emergencies, thank goodness).  He takes Singulair every night, Albuterol as needed and Benadryl as needed (all as suggested by his doctor).  He recently had a cold and his asthma flared up.   We gave him albuterol via his nebulizer 3 times daily for around 6 days (his ped said 4-7 days).    Since the cough wouldn't go away (usually occuring after running around and at night, although sometimes just "on its own") I took him back to his doctor and she said it was indeed his asthma and gave us a Pulmicort Flexhaler, 180mcg.  She told me (and put it on his asthma plan) to have him use the Pulmicort Flexhaler twice, two times a day and to try it for a month  Since then, I've read online that the Flexhaler should be given to children who are 4 with extreme caution and I've read that 180 mcg is the typically recommended dose to start off with.  
     After using the pulmicort for less than a day, my son's coughing has decreased to the point where it is almost gone and we're all very happy about that :-).  While I am VERY happy about his fantastic improvement, because I want him to be well and I want to protect his sweet little lungs, I am wondering if the dose that I am giving him is too much and is in the wrong form (flexhaler instead of the nebulizer type) based upon what I've read online.  Do you have any thoughts about using a Pulmicort Flexhaler with a 4 1/2 year old and at the maximum dosing level?  
Thank you so much for your help!  

[National Jewish Health]

As you know the clinical trials of Pulmicort Flexhaler® (budesonide inhalation powder) were performed on children age 6 and above.  Since we know the medicine is safe for use in very young children from Pulmicort Respules™ (budesonide inhalation suspension) the most likely reason they chose 6 and above was because many children less than age 6 would not be able to use this delivery device effectively.

The recommended dose for this age group is 180 mcg via Flexhaler twice daily, but up to 360 mcg twice daily is deemed acceptable.  The nebulized "medium dose" for children up to 4 years of age is 500 to 1000 mcg daily.  Granted that the actual dose delivered differs from one delivery system to another, this nebulized dose still suggests that the Flexhaler dose recommended by your son's doctor, 180 twice daily, is really not out of that range.

One month is short term therapy and I suspect his doctor plans to reduce the dose at that time.  The real concern with this class of medicines is with the use of high doses of an inhaled steroid for extended periods of time, such as 2 to 4 weeks, and the side effects that result from the high dose.

And, another way to look at this is as a steroid "burst" for the treatment of an asthma exacerbation.  All recommendations for the use of inhaled steroids recommend that once the asthma or his cough is clearly controlled, the dose be stepped-down to the lowest effective dose.  Your son's rapid response suggests that it will be possible to reduce the dose of inhaled steroid, shortly.  You should share your concern with his doctor and ask, if his cough remains controlled after 2 weeks therapy, would it then be appropriate to reduce the daily dose to 180 mcg.

Be assured that your son and his lungs will not be harmed by a dose of 180 to 360 mcg for a few weeks.

[Jennymom]

     Thank you for your response, it was very informative and has eased my mind greatly.  I appreciate your time and efforts more than you know... my children are of the utmost importance to me and I always feel the need to know the most I can about topics that concern their health and well-being.  Kudos to you, your knowledge, and your willingness to take the time to share it!
     I have actually been to my son's doctor's office (for a non-asthma concern) and I discussed my son's improvement with his doctor.  I asked if it would be okay to reduce his dose and see if his asthma remained under control at the lesser dose.  His doctor thought that was a good idea, so I immediately reduced his dose.  His asthma is still well under control with a single dose in the morning and in the evening.  Yay!

Thanks and Best Wishes,
Jennymom