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pulm.asthma.peds.v1

Pediatric asthma (chronic stepwise + acute exacerbation)

pediatricschronicacutepediatricoutpatientacuteinpatient
Start encounter →Print handoutPRODUCTION

GINA 2026 + RxCUI SWEEP (2026-05-25): combination-inhaler codes RxNav-validated to SCDs — budesonide-formoterol 19831→1246304, fluticasone-salmeterol 41126→896184 (SBD 896185). Single-ingredient codes confirmed correct (fluticasone-propionate 50121, prednisolone 8638, dexamethasone 3264, epinephrine 3992, omalizumab 302379, mepolizumab 1720597, dupilumab 1876376, tezepelumab 2587789, albuterol 435, montelukast 88249). depemokimab deliberately NOT added — it is ≥12-only (adult engine pulm.asthma.core.v1); this peds engine covers ≤5 + 6–11 yr. Stale GINA 2025 refs → 2026. last_reconciled→2026-05-25. Depth-pass 2026-05-16: GINA-2026-peds reconciliation + Bayesian/differential-as-data. evidence.pmids rebuilt to 14 PubMed-verified codes (get_article_metadata 2026-05-16); prior POINT 29766750 + REDUCE 23900119 were wrong-engine fillers — CULLED. last_reconciled=2026-05-16. Effect-size anchors (peds-specific, ≥10): dex-vs-pred 5d relapse RR 0.90 / 10-14d RR 1.14 / ED-vomiting RR 0.29 (Keeney 24515516); IV MgSO4 peds admission OR 0.32 95%CI 0.14-0.74 (Griffiths 27126744); CAMP adult-height -1.2 cm 95%CI -1.9 to -0.5 at budesonide 400 µg/d, -0.1 cm per µg/kg (Kelly 22938716) + no HPA suppression (Bacharier 15173493); mepolizumab MUPPITS-2 6-11 yr 40 mg exac rate ratio 0.73 95%CI 0.56-0.96 (Jackson 35964610); dupilumab VOYAGE eos/FeNO-predictive 6-11 yr (Bacharier 38272375) + weight-tiered PK 100/200 mg (Jackson 36958470); SYGMA1 as-needed bud-form severe-exac rate ratio 0.36 95%CI 0.27-0.49 vs SABA (29768149) + SYGMA2 non-inferior to maintenance 0.97 (29768147); PRAM responsiveness 0.7 / post-BD r=0.5 vs admission (Ducharme 18346499); ipratropium NO ward LOS benefit MD -0.28 h bounding it to ED-only (Vézina 25080126). RxCUI sanity-check vs RxNav REST 2026-05-16: FIXED magnesium_sulfate 8814→6585 (8814 resolved to epoprostenol — wrong drug). Combination inhalers carry base-ingredient CUIs not SBD/SCD: budesonide-formoterol 19831=base budesonide (true SBD 389132), fluticasone-salmeterol 41126=base fluticasone (true SBD 284635) — flagged NEEDS_RXNAV_VALIDATION, NOT hand-authored per regimen-builder-template policy. albuterol 435, fluticasone-propionate 50121, montelukast 88249, prednisolone 8638, dexamethasone 3264, methylprednisolone 6902, ipratropium 7213, tiotropium 69120, omalizumab 302379, mepolizumab 1720597, dupilumab 1876376, tezepelumab 2587789, epinephrine 3992 all verified to correct ingredient. §5.5.2 differential-as-data: age-conditioned discriminator table encoded in severity_triggers (differential_peds_asthma_vs_mimics, pram_pass_disposition_mapping) + sibling_differentiation (4 engine_ids: pulm.asthma.core.v1 adult, peds.bronchiolitis.v1, pulm.cap.peds.v1, allergy.anaphylaxis.v1) + workups[].branches_to. Schema gap: EngineDossier has no first-class LR/pretest/decision-threshold field — narrative encoding (see depth.md §schema-gap). SCHEMA-GAP: SettingPlaybook has NO handoff field (only SettingTransition.handoff exists). Depth brief §3 draft handoff:{} object on setting_playbooks[ed] would have been an invented field + typecheck failure — instead encoded as 5 schema-valid SettingTransition records (ED→ward admit, ED→ICU escalation, ED→home discharge, ICU→ward de-escalation, ward→home discharge) with handoff[] discharge-composer fuel. PRAM/PASS wired as RequiredCalculator (calc.pram drives disposition; calc.pass severity_classification) — both resolve in clinical-tools-registry.ts. Regimen encodes ≥5 special-population branches as RegimenDrug.triggers + special_pop: contraindication_rules (preschool episodic-vs-daily ICS, growth/ICS-minimisation, exercise-induced, adolescent-adherence/transition, obesity). OPEN: no manifest / atoms / package on disk yet (manifest field intentionally empty). PRAM/PASS/cACT calculator entries exist in registry. Companion: _briefs/pulm.asthma.peds.v1.md (design brief), _briefs/pulm.asthma.peds.v1.depth.md (depth payload), _research-bundles/pulm.asthma.peds.v1.md (evidence bundle).

Entry points (6)

  • symptom
    Recurrent wheeze, cough, dyspnea in a child (GINA 2026)
    recurrent_wheeze_child
  • symptom
    Exercise-induced wheeze / cough (GINA 2026)
    exercise_induced_wheeze
  • symptom
    Severe acute exacerbation in child (accessory muscles, retractions, SpO2 <92%, silent chest) (BTS/SIGN 2024)
    severe_acute_pediatric_asthma
  • history
    SABA over-use (>1 canister/3 mo) — review needed (GINA 2026)
    high_saba_use_child
  • problem_list
    Existing pediatric asthma — control review / step titration (NAEPP EPR-4 2020)
    pediatric_asthma_existing
  • lab_abnormality
    Spirometry (≥6 yr): reduced FEV1/FVC with bronchodilator reversibility ≥12% (GINA 2026)
    fev1_reduced_reversible_peds

Required inputs (21)

  • agerequired
    demographic • used at CONTEXT
    <5 vs 6-11 vs ≥12 yr defines pathway, drug formulation, and step ladder (GINA 2026)
  • weightrequired
    demographic • used at CONTEXT
    All rescue dosing is weight-based (SABA neb 0.15 mg/kg, IV mag 25-50 mg/kg, prednisolone 1-2 mg/kg) (NAEPP EPR-4 2020)
  • spo2required
    vital • used at CONTEXT
    Severity gate — admission threshold (<92%); supplemental O2 trigger (BTS/SIGN 2024)
  • rrrequired
    vital • used at CONTEXT
    Tachypnea by age band drives severity and respiratory failure recognition (GINA 2026)
  • hrrequired
    vital • used at CONTEXT
    Tachycardia by age + β2-agonist toxicity surveillance (GINA 2026)
  • peak_flow_pef
    vital • used at RISK_STRATIFICATION
    PEF % personal best (≥6 yr) — drives severity tier and zone of action plan (GINA 2026)
  • work_of_breathingrequired
    symptom • used at CONTEXT
    Retractions, accessory muscle use, nasal flaring, paradoxical breathing — age-appropriate severity (BTS/SIGN 2024)
  • mental_status_childrequired
    symptom • used at RED_FLAGS
    Drowsy, agitated, exhausted = life-threatening sign in a child (BTS/SIGN 2024)
  • exacerbations_12mo_childrequired
    history • used at CONTEXT
    Step-up trigger; ICU admission history is a future-risk marker (GINA 2026)
  • inhaler_technique_spacerrequired
    history • used at CONTEXT
    Spacer required <5 yr; technique audited BEFORE step-up (GINA 2026)
  • atopic_comorbidity
    history • used at CONTEXT
    Eczema / allergic rhinitis / food allergy — atopic march phenotype (GINA 2026)
  • environmental_triggers
    history • used at CONTEXT
    Tobacco smoke, mold, pets, viral URI seasonality (NAEPP EPR-4 2020)
  • blood_eos
    lab • used at INITIAL_WORKUP
    T2 phenotype — biologic candidacy at step 5 (≥6 yr) (GINA 2026)
  • feno
    lab • used at INITIAL_WORKUP
    T2 inflammation marker (≥5 yr can attempt) (GINA 2026)
  • total_ige
    lab • used at INITIAL_WORKUP
    Omalizumab eligibility (≥6 yr) (GINA 2026)
  • potassium
    lab • used at TREATMENT
    Hypokalemia after high-dose / continuous β2-agonist (NAEPP EPR-4 2020)
  • lactate
    lab • used at TREATMENT
    β2-agonist-mediated lactic acidosis; mimics sepsis (NAEPP EPR-4 2020)
  • vbg_or_abg
    lab • used at RED_FLAGS
    Severe exac: rising / normalising PaCO2 = impending respiratory failure (BTS/SIGN 2024)
  • spirometry
    imaging • used at INITIAL_WORKUP
    Diagnosis confirmation (≥6 yr); FEV1, FEV1/FVC, reversibility (GINA 2026)
  • cxr
    imaging • used at INITIAL_WORKUP
    Severe / atypical: rule out foreign body, pneumothorax, pneumonia (BTS/SIGN 2024)
  • current_medsrequired
    medication • used at CONTEXT
    Baseline controller + β-blocker/NSAID exposure; adherence (GINA 2026)

12-phase flow (12)

  1. 1FRAME
    Confirm pediatric asthma diagnosis (recurrent wheeze with reversibility / Asthma Predictive Index in <5y) vs viral wheeze, foreign body, anatomic airway, CF, bronchiolitis (GINA 2026)
    inputs: age
    advance: Diagnosis pattern fits pediatric asthma
  2. 2ENTRY
    Stepwise control review or acute exacerbation triage (GINA 2026)
    inputs: age, weight
    advance: Trigger captured (control review vs acute)
  3. 3CONTEXT
    Control level, exacerbations 12 mo, inhaler/spacer technique, adherence, atopy, environmental triggers (tobacco smoke), school/sport limitation (NAEPP EPR-4 2020)
    inputs: exacerbations_12mo_child, inhaler_technique_spacer, rr, spo2, hr, work_of_breathing, current_meds
    advance: Control + technique audited
  4. 4RED_FLAGS
    Life-threatening exacerbation: silent chest, exhaustion, drowsiness/agitation, SpO2 <92%, cyanosis, normalising/rising PaCO2 (BTS/SIGN 2024)
    inputs: spo2, rr, mental_status_child, vbg_or_abg
    advance: No life-threatening features OR escalated to ICU pathway
  5. 5INITIAL_WORKUP
    Spirometry with reversibility (≥6 yr); PEF diary; atopy panel; CXR + VBG/ABG if severe acute; T2 biomarkers at step 4-5 (GINA 2026)
    inputs: spirometry, blood_eos, feno, total_ige, cxr
    actions: workup.severe_asthma_exac, workup.pediatric_fever
    advance: Phenotype + acute severity assigned
  6. 6BRANCHING_WORKUP
    Severe / refractory: rule out foreign body (sudden onset), anaphylaxis, pneumothorax, vascular ring, vocal cord dysfunction, immunodeficiency if recurrent pneumonia (GINA 2026)
    advance: Mimics excluded
  7. 7DIFFERENTIAL
    Allergic-eosinophilic / virus-induced wheeze / exercise-induced bronchoconstriction / occupational exposure (older adolescent) (GINA 2026)
    advance: Phenotype assigned
  8. 8RISK_STRATIFICATION
    GINA / NAEPP control level; future risk (prior PICU, ≥2 OCS bursts, low FEV1, food allergy, tobacco exposure); acute severity tier (GINA 2026)
    inputs: exacerbations_12mo_child, peak_flow_pef
    advance: Control + acute severity + risk profile documented
  9. 9TREATMENT
    GINA 2026 Track 1 pediatric stepwise (6-11 yr): low/medium/high ICS-formoterol; <5 yr ICS daily + SABA PRN, montelukast as alt, refer if step ≥3. Acute: O2 to 94-98%, weight-based SABA neb 0.15 mg/kg (min 2.5 mg, max 5 mg) ± ipratropium, oral prednisolone 1-2 mg/kg (max 60 mg) × 3-5 d, IV magnesium 25-50 mg/kg (max 2 g) for severe / poor first-hour response, NIV/intubation if respiratory failure (GINA 2026; NAEPP EPR-4 2020)
    inputs: blood_eos, feno, total_ige, spo2, peak_flow_pef, weight
    advance: Step + acute regimen + biologic candidacy + trigger plan documented
  10. 10DISPOSITION
    Acute: home (mild + good response after first hour) / admit (moderate-severe with incomplete response) / PICU (life-threatening, hypercapnia, exhaustion); chronic: severe-asthma referral if step ≥4 with ≥2 exacerbations/yr (BTS/SIGN 2024)
    advance: Disposition + level of care set
  11. 11MONITORING
    Acute: hourly SpO2, RR, work-of-breathing; K+/lactate after continuous neb; VBG q1-2h if hypercapnic. Chronic: control review at 4-6 weeks; growth velocity on ICS; spacer technique re-audit (GINA 2026)
    inputs: potassium, lactate, vbg_or_abg
    advance: Review interval scheduled and adherence supports plan
  12. 12FOLLOWUP
    Written pediatric asthma action plan, school plan, vaccinations (flu, pneumococcal, COVID), tobacco-smoke counselling, allergen control, growth monitoring, primary-care follow-up within 1 week of any ED/admission (GINA 2026; AAP)
    advance: Action plan + school plan + vaccinations + 1-week follow-up complete