This does not cover the acute management of asthma. For acute management, see PAU – wheeze in children.
This is intended to be a guide for managing chronic asthma in children over 5 years of age.
Diagnosis of asthma in children is clinical and based on the BTS/Sign guidelines 2019 which states that factors involved in a clinical assessment include:
More than one of the symptoms of wheeze,
breathlessness, chest tightness and cough occurring in episodes with periods of
no (or minimal) symptoms between episodes. Note that this excludes cough as an
isolated symptom in children.
a documented history of acute attacks of
wheeze, triggered by viral infection or allergen exposure with symptomatic and
objective improvement with time and/or treatment
recurrent intermittent episodes of symptoms
triggered by allergen exposure as well as viral infections and exacerbated by
exercise and cold air, and emotion or laughter in children.
An historical record of significantly lower
FEV₁ or PEF during symptomatic episodes
compared with asymptomatic periods provides objective confirmation of the
obstructive nature of the episodic symptoms.
Wheeze confirmed by a
healthcare professional on auscultation
It is important to distinguish wheezing
from other respiratory noises, such as stridor or ‘rattly’ breathing.
normal examination of chest when symptomatic reduces the probability of asthma.
Evidence of diurnal
Symptoms which are worse at night or in the
Personal history of an atopic disorder (ie
eczema or allergic rhinitis) or a family history of asthma and/or atopic
disorders, potentially corroborated by a previous record of raised
allergen-specific IgE levels, positive skin-prick tests to aeroallergens or
Absence of symptoms, signs or clinical history to suggest alternative diagnoses
Children with a high probability of
asthma based on clinical assessment, should be commenced on a 6 week course of
standard asthma treatment, which is usually an inhaled corticosteroid with
salbutamol as a reliever. There should
be a review in place at 6-8 weeks which should assess response, using PEFR as
an objective measure if the child is able and old enough. If there is little, or no response, consider:
The possibility of alternative diagnoses
Medication technique and compliance
Whether they need a paediatric opinion (see
under ‘Referral Information’)
If there is a good response to initial treatment, please titrate inhaled corticosteroids to the lowest dose which controls symptoms, and ensure that good education has taken place. This should include a written ‘Allergy Action Plan’, and a plan for regular medical review. Discuss avoidance of possible triggers such as domiciliary cigarette and other smoke.
For children with an
established diagnosis of asthma, who are undergoing community review it is
important to consider:
What is the use of reliever (usually salbutamol)
therapy? How frequently is it required?
Are there interval symptoms – nocturnal cough or
exercise induced cough/wheeze?
Have they needed oral steroids for an acute
attack, either in primary or secondary care?
Have they needed emergency care (may not
necessarily result in treatment with steroids)
Has the child completed the ‘Asthma Control
Test’ specific to their age group? A
link can be found in ‘Supporting Information’.
What is their compliance with medication like
(both self-reported and objectively from practice records)?
What is their height and weight, as plotted on
an appropriate age-specific centile chart?
What is the PEFR and is this appropriate for
How many prescriptions have been filled for
preventers (usually salbutamol from the practice)?
Are there smokers in the family? Has smoking
cessation advice been discussed?
Are there pets at home – has the possibility of
allergy been discussed?
Is there a possible issue with house dust mite?
Has reduction of dust mite exposure been broached?
Is this seasonal – either related to Autumn/winter
viruses or pollen in summer?
Is this affecting education? What time have they
had off school due to health?
Consider compliance with medication/inhaler
technique (see under management)
Do the family know the advice for action in an
acute attack – do they have a written ‘Asthma Action’ plan?
Every medical encounter is an opportunity to educate
children and parents/carers about their asthma.
This should involve:
Discussing emergency regimes/treatment,
including when and how to seek urgent medical help
Medication – compliance with prescribed
medications and inhaler technique
Providing or reviewing a written ‘asthma action’
Discussing any triggers or exacerbating factors
Eliciting any psychosocial factors which may
have an impact, including family support, mental health, any safeguarding
Children who have the following ‘Red Flags’ should be
referred for advice:
The following table shows the dose of standard non-proprietary
beclomethasone inhaler dose:
Very low dose
2 puffs twice daily
2 puffs twice daily
2 puffs twice daily
Children and parents should be given standard inhaler
technique advice. An MDI inhaler should
always be given via a spacer in children.
In young children (< 6 years), the spacer should come with a mask and
it is important to check that this fits snugly over nose and mouth. In older children, a spacer with a mouthpiece
is recommended but it is important to check that they can manage a good seal
with their lips around the mouthpiece.
The spacer should be cleaned monthly by washing in hot water
and washing up liquid. They should be advised to leave it to air dry (rather
than rubbing with a tea towel which creates static and reduces drug delivery to
the lungs). They will need to be changed for a new spacer every 6-12 months.
Children on regular inhaled corticosteroids should be
advised to brush their teeth and rinse their mouth after taking the
Peak flow (PEFR) is difficult to do reliably in young
children. From the age of 6 years,
children can start to practice performing a peak flow as part of their standard
asthma reviews. This should be plotted
on a normogram for height and age. Initial
attempts are likely to be inaccurate, as it takes practice to develop a good
technique. The below is a video for
parents on how to perform peak flow.
Children should have their height and weight plotted in the
Red Book or appropriate age-specific centile chart.
A child who is obese according to a centile BMI chart,
should be referred for dietary advice and intervention. Education regarding healthy diet and weight
maintenance should be offered to all children and families.
Smoking cessation advice and available resources should be
offered to Young People and parents who smoke.
Once control has been achieved, it is important to maintain
children on the lowest possible dose of inhaled corticosteroids – this should
be reviewed every 3 months with a view to reducing steroids, where possible by
25-50% of starting dose.
There may be co-existing rhinitis which can be treated with
intra nasal steroids as a first line therapy.
Always be mindful of
any safeguarding or psychosocial factors.
Reviews of childhood asthma deaths suggest that children who have
multiple missed appointments, poor medication compliance, high SABA use and a
previous life-threatening asthma presentation are at higher risk of a further
life threatening presentation.
For Children with any ‘red flags’ or ‘additional
considerations’ should be referred to Paediatric Outpatients via ERS, with as
much supporting information as possible.
Children who are on regular very low dose ICS plus either a
LABA or LTRA and have not achieved adequate control of symptoms should also be
sent for Paediatric Assessment in outpatients via ERS.
It is important that children bring their current inhalers and spacer
devices with them to the appointment. This is so we can check inhaler technique
as part of the appointment. It is also important for parents to bring their
copy of the ‘asthma action’ plan.
If you are unsure, we are happy to discuss the child with you – if the child is known to a Consultant here, you can ask them to call you back by leaving a message with the Paediatric Admin Office. If they are not known to us yet, please ask for advice via Advice & Guidance on ERS or the Paediatric Advice Telephone.
For the full BTS/Sign guideline, please click on link below
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