Updated October 2025
Clinician Brief
Pediatric Asthma Management and Adherence: Evidence-Based Strategies
Adherence to pediatric asthma therapy is frequently suboptimal and declines with age. Evidence highlights the central role of caregiver beliefs, social context, and health-system supports. High-reliability care requires accurate diagnosis, individualized pharmacotherapy, adherence monitoring (frequency, technique, and prescribing fidelity), and targeted behavioral and educational interventions. Integrating youth-centric tools, school–home coordination, and family-centered strategies improves outcomes.
Clinical question
What evidence-based strategies optimize pediatric asthma management and improve adherence to controller therapy?
AsthmaPediatricsAdherenceInhaled corticosteroidsSelf-managementCaregiver engagement
Key points
Confirm diagnosis and phenotype before escalating therapy
Asthma management rests on accurate diagnosis and phenotyping; tailor pharmacotherapy, address comorbidities, and follow stepwise care while checking inhaler technique and adherence at every visit [4], [5].
Measure adherence as frequency, technique, and prescribing fidelity
Adherence comprises the rate of use, correct device technique, and whether the regimen was prescribed/dispensed as intended—each requires separate assessment and intervention [6].
Identify high-risk nonadherence
Older age, longer treatment duration, and certain sociodemographic factors predict lower adherence; flag these for proactive follow-up [7], [8], [1].
Align treatment with patient/parent beliefs
Address necessity–concern beliefs, side-effect worries, and stigma; structured conversations improve acceptance and daily use of inhalers [3], [9].
Use youth-centric self-management supports
Interactive, literacy-appropriate, and school-integrated tools enhance engagement and reduce the burden of self-management for children and adolescents [10].
Evidence highlights
≈48% of prescribed doses in children [1]
Typical adherence to controller therapy
Worse morbidity on 8/9 measures when nonadherence admitted [2]
Caregiver-reported nonadherence impact
Necessity beliefs consistently associated with adherence (12/12 BMQ studies) [3]
Belief–adherence link
Practical, Stepwise Management with Adherence Integration
Embed adherence assessment and behavioral supports into every step of pediatric asthma care.
1
Verify the diagnosis and severity
Confirm variable respiratory symptoms and variable expiratory airflow limitation when feasible; assess triggers and comorbidities (allergic rhinitis, obesity, GERD, anxiety). Establish baseline control and risk for exacerbations before therapy changes [4], [5].
2
Choose age-appropriate pharmacotherapy
For persistent asthma, prioritize ICS-containing regimens; escalate stepwise based on control and exacerbation risk. Consider recent advances for severe asthma (e.g., biologics for selected phenotypes) after adherence/technique optimization [5], [4].
3
Assess and optimize adherence at each visit
Measure three pillars: frequency (refill/electronic monitors), technique (checklist with demonstration), and prescriber fidelity (correct device/dose/supply). Correct errors before stepping up therapy [6].
4
Address beliefs, barriers, and behaviors
Elicit necessity–concern beliefs, side-effect worries, stigma, and family routines. Provide clear benefit–risk framing for ICS, normalize use at school, and co-design a feasible daily plan with caregivers/teens [3], [9], [10].
5
Implement self-management education
Deliver written, personalized action plans; teach symptom/peak flow-based steps; integrate reminders and school nurse coordination. Use teach-back to confirm understanding [10], [4].
6
Monitor outcomes and iterate
Track symptom control, SABA use, exacerbations, and QoL. If control poor, re-check adherence and technique first; then adjust dose/device or consider add-ons and specialist referral if severe [4], [5].
Adherence Risk, Detection, and Interventions
Use these structured checklists in clinic to identify and close adherence gaps.
Risk factors for nonadherence
Older child/adolescent age; longer treatment duration [7], [1]
Minority status, lower SES, caregiver stress/health behaviors [8], [1]
Negative treatment beliefs, side-effect concerns, stigma/embarrassment [3], [9]
Complex regimens, multiple devices, poor health literacy [10], [4]
Limited school support or fragmented home–school communication [10], [9]
Efficient adherence detection
Objective data: pharmacy refill, dose counters, electronic monitors when available [6]
Inhaler–spacer technique observation with checklist; re-demonstrate until correct [6]
Brief beliefs screen: necessity vs concerns; ask about side effects and routines [3]
Cross-check prescriber fidelity: correct dose/device, refills supplied, written plan given [6]
Use caregiver ‘admitted nonadherence’ questions—predictive of morbidity [2]
Core interventions that work
Simplify to once-daily ICS or single maintenance-and-reliever therapy where age/guidelines allow; minimize device types [4], [5]
Motivational interviewing to resolve ambivalence; align with family goals [3], [9]
Structured education with teach-back and written action plan; school coordination [10], [4]
Reminder systems: phone alarms, apps, smart inhalers; involve caregivers for refills [6]
Regular technique ‘booster’ sessions; spacer use in younger children [4], [6]
When to consider advanced therapies
After confirming poor control despite verified adherence/technique over time [4], [5]
Phenotype-driven add-ons and biologics for severe, uncontrolled disease [5]
Multidisciplinary review: allergy testing, environmental control, comorbidity management [4], [5]
Monitoring outcomes and safety
Track ACT/C-ACT scores, SABA canister counts, ED/OC visits, oral steroid bursts [4]
Growth monitoring with long-term ICS; discuss expected small effects and risk–benefit [4]
Document adherence metrics (frequency, technique, fidelity) at each visit [6]
Key Findings on Adherence and Outcomes
High-impact findings that inform clinical practice.
Observed adherence levels
Average pediatric adherence ≈48% of prescribed doses; declines with age (r = −0.21) [1]
Preschool and school-age children show frequent missed doses without structured supports [11]
Clinical impact of nonadherence
Caregiver ‘admitted nonadherence’ associates with worse morbidity on 8/9 measures (hospitalizations, symptoms, activity limits) [2]
Nonadherence indicators in primary care can be identified for targeted interventions [12]
Determinants of adherence
Beliefs about necessity consistently predict adherence across studies; concerns about side effects and safety reduce use [3]
Family-level factors (SES, race/ethnicity, health behaviors) frequently correlate with adherence [8]
Self-management and systems
Children and adolescents can engage in self-management when provided interactive, youth-centric, literacy-matched tools [10]
Childhood asthma management is often suboptimal; empowering caregivers is central to daily control [9]
Modern therapy landscape
Guidelines emphasize ICS-containing regimens across severity with stepwise adjustment [4]
New biologics and tailored strategies have expanded options for severe pediatric asthma [5]
References
Source material
Primary literature that informs this article.
Medication adherence in pediatric asthma: reasoning, ...
pubmed.ncbi.nlm.nih.gov
Relationship of adherence to pediatric asthma morbidity ...
clinicaltrials.gov
Treatment perceptions in patients with asthma: Synthesis of ...
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Asthma Management in Children
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Asthma prevention and recent advances in management
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Medication Adherence in Children with Asthma - PMC
pmc.ncbi.nlm.nih.gov
Predictors of protocol adherence in a pediatric asthma ...
clinicaltrials.gov
Medication adherence in pediatric asthma: A systematic ...
onlinelibrary.wiley.com
Children's, parents' and health professionals' views on the ...
www.nature.com
Children and young people's self-reported experiences of ...
www.sciencedirect.com
Compliance with inhaled asthma medication in preschool ...
pmc.ncbi.nlm.nih.gov
Indicators of Non-adherence to Asthma Treatment in ...
www.sciencedirect.com
New approaches in childhood asthma treatment
journals.lww.com
Adherence to therapy regimen by children with asthma and ...
pmc.ncbi.nlm.nih.gov