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 is a clinical one; there is no single confirmatory diagnostic blood test, radiological investigation or histopathological investigation. Asthma is to be suspected in any child with wheezing, ideally heard by a health professional on auscultation and distinguished from upper airway noises.

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)

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

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 spirometry should be available over the course of 24/25 in general practice. There is some access to FeNO in general practice

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:

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 can be used in those where asthma 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 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/Wheeze Action Plan
• Teenage Asthma Plan (Maintenance & Reliever Therapy - MART)
• Teenage Asthma Plan (Preventer Medications - non-MART)

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.

Children with hospital admission for asthma or 2 ED presentations in 12 months should be followed in 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)

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 2024/25 (england.nhs.uk) - pages 61-66.

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.