A 7-year-old girl on low-dose ICS and SABA for three months still has symptoms three times a week and wakes at night once a week; she cannot manage MART. What is the next step in her asthma treatment plan?

• A. Add a leukotriene receptor antagonist
• B. Increase ICS dose
• C. Switch to MART
• D. Start oral steroids

Answer: (A)

When asthma control is not achieved on low‑dose inhaled corticosteroids, you look for an additional controller option rather than jumping straight to systemic steroids. For a school‑age child who cannot manage a MART regimen, adding an oral leukotriene receptor antagonist offers a convenient, steroid‑sparing way to improve control by targeting leukotriene‑driven inflammation that contributes to both daytime symptoms and nighttime awakenings.

Montelukast is approved for children in this age group and is taken orally, which can help with adherence and reduce the need for higher inhaled steroid doses. It can also help if allergic rhinitis is present, since leukotrienes are involved in both conditions. While increasing the ICS dose is another valid route, the question’s context emphasizes a non‑inhaled add‑on when MART isn’t feasible, making the leukotriene receptor antagonist a suitable next step.

Starting oral steroids is generally reserved for more severe or acutely uncontrolled cases due to systemic side effects, and switching to MART isn’t possible here since the patient cannot manage it.