Identifying Low-Risk Children With Intermittent Asthma

Research suggests opportunities to refine treatment guidelines and reduce unnecessary medication use.

In the medical community, there is an ongoing debate over the Global Initiative for Asthma guidelines, which discourage the use of short-acting beta-agonists (SABAs) alone, in patients with mild asthma. Instead, the guidelines advise adding as needed anti-inflammatory therapy as a first step. This is typically low-dose inhaled corticosteroids (ICS), either taken with a SABA (in younger children) or in combination with a fast-acting bronchodilator such as Formoterol (in adolescents and adults) on an as-needed basis. This strategy is intended to reduce the risk of severe exacerbations.

These recommendations apply to patients with both intermittent and mild persistent asthma, which together are labeled as “mild asthma.” Intermittent asthma accounts for a substantial portion of the overall asthma population worldwide. As a result, millions of patients with stable disease may be exposed to treatment escalation despite having a low baseline risk of severe outcomes.

To better understand this risk, a recent study published in Chest examines whether all children with intermittent asthma require this therapeutic approach.

Shahid Sheikh, MD

Led by Shahid I. Sheikh, MD, pediatric pulmonologist at Nationwide Children’s Hospital and professor of clinical pediatrics at The Ohio State University College of Medicine, the research team analyzed administrative claims data from more than 13,000 children ages 2 to 18 years. These patients were diagnosed with intermittent asthma and enrolled in Ohio Medicaid managed care plans over a three-year period. The goal was to identify whether a subgroup exists with very low risk for severe exacerbations and limited need for additional therapy.

“Current guidelines recommend this therapy in all patients with mild asthma,” Dr. Sheikh explains. “However, any long-term medication use increase both cost and risk for side effects. If there is a subgroup of children who are consistently low risk, we should understand who they are and whether additional medications, even on an as-needed basis, are truly necessary.”

The investigators used two years of data to identify a “low-risk” cohort. These patients had no hospitalizations, emergency department visits or urgent care visits, and no use of daily asthma medication or systemic steroids for two years. The patients also demonstrated limited reliance on rescue medication, defined as no more than two SABA canisters per year for two years. Outcomes were then assessed in the third year to evaluate whether this low-risk status persisted over time.

Of the 3,935 low-risk children, very few had serious outcomes in year three. Only 0.08% were hospitalized and emergency visits were rare (less than 1%). This group had far fewer severe exacerbations than higher-risk patients.

“These findings dispute the assumption that all asthma patients carry similar risk,” Dr. Sheikh explains. “There are children with intermittent asthma who remain consistently stable and may not require the addition of as needed ICS or ICS/Formeterol as first step therapy for mild asthma.”

The study also evaluated the clinical and economic effects of treating this low-risk population under current guideline recommendations. Researchers calculated that in the low-risk cohort, more than 5,500 patients must be treated to prevent a single hospitalization. Correspondingly, the estimated cost to prevent one hospitalization using even one canister of ICS per year approaches $780,000 and using one canister of ICS/Formeterol/year costs about $1.5 million. This prompts critical questions about value-based care in this population.

“These are not insignificant numbers,” says Dr. Sheikh. “When the baseline risk is very low, the extra benefit from more medication is small. Yet, the costs and treatment burden are high.”

The findings also show the need for precision in diagnosis and therapy. Asthma symptoms and severity can fluctuate over time, particularly in children influenced by viral illnesses, seasonal allergens and developmental factors.

“We used two years for monitoring to ensure our patients were truly low risk, not just experiencing temporary symptom stability in one year,” Dr. Sheikh says.

The researchers are not suggesting abandoning current guidelines but rather refining them. “Guidelines are designed to protect patients at the population level,” Dr. Sheikh says. “Our findings suggest we should better identify which patients require additional treatment and which can be safely monitored.”

Reference:

Sheikh S, Eisner M, Wheaton K, Ulrich L, Palacios S, McCoy KS. Intermittent Asthma and Risk of Severe Exacerbation in Children. Chest. 2026;169(1):41-51. doi:10.1016/j.chest.2025.07.4089.

Image Credit: Nationwide Children’s (portrait) & Adobe Stock (header image)