Asthma in Children - Chronic (DRAFT)

Overview

For management of acute asthma or wheeze please see the Asthma - acute (including wheeze) page.

For adults please see the Asthma (adults) page

Diagnosis

The diagnosis of asthma should be made after taking a structured clinical history. Asthma may be suspected in children with variable wheezing, noisy breathing, cough, breathlessness or chest tightness. Information should be sought about triggers for symptoms and family history of asthma or allergic rhinitis. In children with a history consistent with asthma supportive objective testing should be sought to confirm this diagnosis.

Children under 5 years

For children under 5 with suspected asthma (interval symptoms and another atopic disorder or severe acute episodes requiring admission/oral steroids), treat with an 8-12 week trial of twice daily low dose inhaled corticosteroids and review the child at least annually. If they still have symptoms when they reach 5 years, attempt objective testing.

Children 5-16 years

Objective tests should be ordered and interpreted as per the algorithm Objective Tests For Diagnosing Asthma In Children Aged 5 To 16 With A History suggesting asthma

See pages 3-5 of the UHBW Asthma: diagnosis and management of Chronic Asthma guidelines for details (flow pathway on page 5).This includes a differential diagnosis guide for children with persistent or recurrent wheeze.

Access to objective testing

There is no direct access to secondary care skin prick testing, spirometry or a FeNO service for children in BNSSG and requests to paediatrics for these tests will be returned. 

Referral for a paediatric opinion or further testing should only be considered if there is poor response to treatment or diagnostic uncertainty (see Who to Refer section below).

Management

The majority of children and young people with asthma can be managed in primary care.

See BNSSG Asthma Prescribing Guidelines 2022 – Children & Young People. 

MHRA Guidance on use of SABA : Healthcare professionals should be aware of the change in guidance that no longer recommends prescribing SABA without an inhaled corticosteroid.

Action plans and inhaler technique

Local Asthma action plans have been developed in BNSSG. These should be download and given to parents to support  acute management:

• Child Asthma/Wheeze Action Plan
• Teenage Asthma Plan (Maintenance & Reliever Therapy - MART)
• Teenage Asthma Plan (Preventer Medications - non-MART)

Who to Refer

Children under 5 years

Refer for specialist assessment if the child's asthma does not respond to low dose ICS trial or if after a positive response is uncontrolled on a paediatric moderate dose of ICS as maintenance therapy and a trial of an LTRA has been unsuccessful or not tolerated, stop the LTRA and refer the child to a specialist in asthma care for further investigation and management after checking inhaler technique / adherence / environmental triggers.

Refer for specialist assessment any preschool child with an admission to hospital, or 2 or more admissions to an emergency department, with wheeze in a 12-month period

Children 5-16 years

If there is still doubt about the diagnosis, after a structured clinical history and objective testing refer to a paediatric specialist for a second opinion.

Refer children if their asthma is not controlled on paediatric moderate-dose MART or paediatric moderate-dose ICS/LABA maintenance treatment (with or without an LTRA depending on previous response).

For children with indications for referral, referral can be made via eRS. If age 16 years or over then refer to adult services.

Children with hospital admission for asthma or 2 ED presentations in 12 months should be followed in secondary care asthma clinic.

See page 13 of the UHBW Asthma: diagnosis and management of Chronic Asthma guidelines for details of children who may benefit from referral to the severe asthma clinic in tertiary paediatric respiratory care.

Advice and Guidance-Paediatric asthma advice and guidance is available via eRS for help with advice on diagnosis and/or management

Referral

For children with indications for referral / problematic severe asthma then paediatric respiratory referral can be made via eRS. Clinics are available for children aged under 5 or aged 5 up to 16. If age 16 and over then refer to adult services.

Children with hospital admission for asthma or 2 ED presentations in 12 months should be followed up in the secondary care asthma clinic.

Children meeting any of the criteria below should be reviewed at least annually in the PSA Service: 

1. Prescribed maintenance or frequent courses of oral steroids ≥4 weeks in last year 
2. Admitted to PICU 
3. Under consideration for biological agents or immunosuppressive treatment 
4. On-going poor control despite treatment with high dose ICS plus a LABA (evidence of poor control: symptoms most days for 3 months or ACT < 20, prescription of ≥ 6 reliever inhalers per year, FEV1 < 80% post bronchodilator, ≥ 2 courses oral steroids per year)

Air pollution and Health in Primary Care

Please see the Remedy page on Air pollution and health.

Environmental impact of inhalers

See the BNSSG Formulary respiratory guidelines page for advice and considerations when prescribing inhalers in trying to reduce carbon emissions.

Resources

(1) BTS/SIGN guidelines on the management of asthma -November 2024 - page has links to full guideline and quick guideline.

(2) CKS guidelines on Asthma (all ages) - May 2025

(3) Quality and Outcomes Framework guidance for 2025/26 - pages 41-45.

Efforts are made to ensure the accuracy and agreement of these guidelines, including any content uploaded, referred to or linked to from the system. However, BNSSG ICB cannot guarantee this. This guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, in accordance with the mental capacity act, and informed by the summary of product characteristics of any drugs they are considering. Practitioners are required to perform their duties in accordance with the law and their regulators and nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

Information provided through Remedy is continually updated so please be aware any printed copies may quickly become out of date.