A 9-year-old girl with asthma is using a salbutamol inhaler daily and has peak expiratory flow rate 78% of best. The most appropriate next step is to start regular inhaled corticosteroid therapy. Which option describes the correct starting regimen?

• A. Clenil modulate 100 mcg 1 puff BD
• B. Fluticasone 250 mcg 2 puffs once daily
• C. Montelukast tablet at night
• D. Salbutamol inhaler 2 puffs daily only as needed

Answer: (A)

The key point is that persistent asthma in a child who needs daily relief inhaler and shows reduced lung function requires regular anti-inflammatory therapy with an inhaled corticosteroid. Starting a low-dose ICS helps control the underlying airway inflammation, lowers the frequency of symptoms, and reduces the risk of exacerbations.

Beclometasone 100 mcg per puff, taken as 1 puff twice daily, provides a straightforward, low-dose daily regimen that is appropriate as initial controller therapy in a 9-year-old. It delivers anti-inflammatory effect with relatively low systemic exposure and helps improve peak flow over time as control improves.

The other options aren’t as suitable for starting maintenance. A higher-dose ICS given only once daily carries more exposure and may not maintain steady anti-inflammatory protection throughout the day. Montelukast can be used as an alternative or add-on in some cases, but guidelines favor initiating regular inhaled corticosteroid therapy first for persistent pediatric asthma. Relying on a short-acting beta-agonist alone does not address the inflammation driving asthma and would not constitute proper controller therapy.