Asthma in Children - Chronic

Overview

Please see the following guidelines that are relevant to the diagnosis and managment of asthma in CYP as below:

• Asthma: diagnosis and management of Chronic Asthma - links to comprehensive guidelines provided by Bristol Royal Hospital for Children.
• Asthma prescribing guidelines of children and young people - links to BNSSG formulary local guidance page with up to date details of recommended inhalers for use in CYP.

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

For adults please see the Asthma (adults) page

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.

Diagnosis

The diagnosis of asthma in children and young people is based on recognising characteristic episodic respiratory symptoms and signs in the absence of an alternative explanation.

See pages 3-6 of the UHBW Asthma: diagnosis and management of Chronic Asthma guidelines for details (flow pathway on page 6). This includes a differential diagnosis guide for children with persistent or recurrent wheeze.

QOF (2023) and diagnosis of asthma in children (3)

There is no direct access to secondary care spirometry or a FeNO service for children in BNSSG and requests to paediatrics for these tests will be returned. Access to FeNO testing and spirometry should be made available in each PCN during 2023/24.

Children with asthma can usually be diagnosed without spirometry if this is not available and QOF 2023 gives the following guidance for diagnosis of asthma in children:

'A definitive diagnosis of asthma can be difficult to obtain in young children. Asthma is to be suspected in any child with wheezing, ideally heard by a health professional on auscultation and distinguished from upper airway noises.

Focus the initial assessment in children suspected of having asthma on the:

• Presence of key features in the history and examination
• Careful consideration of alternative diagnoses.

Children (aged 5 to 16) should be diagnosed if they have symptoms suggestive of asthma and:

• a FeNO level of 35 ppb or more and a positive peak flow variability,
• or
• obstructive spirometry and positive bronchodilator reversibility

If a young person or child with symptoms suggestive of asthma cannot perform a particular test, try to perform at least 2 other objective tests. Diagnose suspected asthma based on symptoms and any positive objective test results. Personalised care adjustment (PCA - i.e. exception reporting) is available where people cannot perform objective testing.'

Local clinicians advise that a trial of treatment prior to objective testing should only be used in those where the diagnosis is suspected with high probability. Please also see the advice below from NICE below:

After starting or adjusting medicines for asthma, review the response to treatment in 4 to 8 weeks (2). Validated asthma control questionnaires, peak flow variability and spirometry can be used to monitor response.' 

Referral for a respiratory opinion or further testing should only be considered if there is poor response to treatment or if there are other concerns 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.

Asthma management is multifaceted and comprised of:

• Medical management (including management of comorbidities).
• Supported self-management.
• Annual review - monitoring of disease control and risk reduction (including review of inhaler technique, and medication concordance and adverse effects).

See pages 7-14 of the UHBW Asthma: diagnosis and management of Chronic Asthma guidelines for details (summary on page 10).

Prescribing advice

BNSSG Asthma Prescribing guidelines for children are available in the Formulary Local Guidance section of Remedy.

Asthma Control Test

The Asthma Control Test can be used for children aged 4 and over to assess how well asthma is controlled.

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 Plan
• Teenage Asthma Plan (Maintenance & Reliever Therapy - MART)
• Teenage Asthma Plan (Preventer Medications - non-MART)

Asthma action plan - links to the Asthma UK website for downloadable asthma action plan for children

Help your child use their inhaler - links to the Asthma UK website for advice on use of inhalers in children.

Asthma spacer devices factsheet - links to BNSSG formulary local guidance page for a factsheet on different spacer devices.

Who to refer

See pages 14-15 of the UHBW Asthma: diagnosis and management of Chronic Asthma guidelines for details of children who may benefit from referral to secondary care.

Problematic Severe Asthma

A minority of children and young people have asthma symptoms which remain uncontrolled despite being prescribed high doses of conventional therapy. These children and young people are considered to have problematic severe asthma and need specialist evaluation and treatment by a multi-disciplinary team.

Referral

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.

CYP Asthma Community Clinic Pilot

From September 2022 – March 2023 there is a community clinic pilot in place at various locations across BNSSG for children and young people, aged 4-16 years, with less well controlled asthma*, or where a diagnosis of asthma has not been made and in whom diagnostic testing and a clinical review would be helpful.

Update 31/01/2023: Due to the high number of referrals received for the community asthma clinic and the short term nature of the pilot, we unfortunately must pause from taking any further referrals at this time.

If you require support with a child or young person with asthma, please access the advice and guidance service available on ERS.

We would like to thank our primary care colleagues who have referred CYP over this period. We have received over 200 referrals across 36 practices with positive feedback from children and families. We will be completing an evaluation of the pilot which will be used to shape future models of care for children and young people with asthma.

Resources

(1) BTS/SIGN guidelines on the management of asthma -2019 - page has links to full guideline and quick guideline.

(2) CKS guidelines on Asthma (all ages) - May 2021

(3) Quality and Outcomes Framework guidance for 2023/24 (england.nhs.uk) - pages 50-56.

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.