Management of childhood asthma

See also the separate Diagnosing childhood asthma in primary care article.

What is asthma?

Asthma is the most common respiratory disorder of children. Chronic inflammation of the bronchial mucosa and hyper-reactive airways results in bronchoconstriction and reversible airway narrowing. It typically presents with wheeze, dry cough, difficulty breathing and/or chest tightness. See also Wheezing in children.

Managing childhood asthma involves both an appreciation of current treatment practice and also a willingness to educate and support the child and their family in the longer term.

Acute asthma in children

Acute asthma symptoms

It is vital to recognise the severity of an acute asthma attack. Clinical signs are a poor indicator of the degree of airways obstruction and some with acute severe asthma may not appear distressed.

Always assess and record:

• Pulse rate.

• Respiratory rate.

• Oxygen saturations (SpO₂).

• Degree of breathlessness (for example, ability to complete sentences, and to feed).

• Use of accessory muscles of respiration (feel the neck muscles for involvement in breathing).

• Amount of wheezing (with increasing severity, wheeze may become biphasic or less apparent).

• Degree of agitation and conscious level.

Clinical assessment of the severity of an acute asthma attack in those aged over 2 years¹

Clinical assessment of the severity of an acute asthma attack in those aged under 2 years¹

Children should be monitored carefully and assessed repeatedly to determine the need for admission to secondary care or for transfer to a high-dependency unit (HDU) or paediatric intensive care unit (PICU), where there are features of poorly responsive severe asthma or life-threatening asthma.

Diagnosing acute asthma in children (investigations)

These include:¹

• Peak expiratory flow rate (PEFR) in children aged over 5 years (use best of three readings, expressed as a % of personal best PEFR).

• Oxygen saturation - should be available in primary care, as low oxygen saturations (<92%) after initial bronchodilator therapy indicate a more severe subgroup of patients, in whom inpatient treatment may be required.

• CXRs and arterial blood gases are not routinely indicated, as their information yield is rarely high.

Treatment of acute asthma in children¹²

• Admit (emergency 999) all children with features of a life-threatening asthma exacerbation.

• Admit if any feature of a severe asthma attack persisting after initial bronchodilator treatment.

• Admit if moderate asthma exacerbation with worsening symptoms despite initial bronchodilator treatment and/or who have had a previous near-fatal asthma attack. Children with a moderate exacerbation may also require admission if they have factors that warrant a lower threshold for admission, such as:

  • Poor treatment adherence.

  • Physical or learning disability.

  • Previous severe asthma attack.

  • Exacerbation despite an adequate dose of oral corticosteroids before presentation.

  • Presentation in the afternoon or at night.

  • Recent nocturnal symptoms.

  • Recent hospital admission.

  • Concern over family/social circumstances.

National Institute for Health and Care Excellence (NICE) recommendations for management in children aged 2 years and over

• Children with features of severe or life-threatening acute asthma should start treatment as soon as possible and be referred to hospital immediately following initial assessment.

• Any child who fails to respond to treatment adequately at any time should also be referred to hospital immediately.

• Supplementary high flow oxygen (via a tight-fitting face mask or nasal cannula) should be given to all children with life-threatening acute asthma or SpO₂ <94% to achieve normal saturations of 94-98%.

• First-line treatment for acute asthma is an inhaled short-acting beta₂ agonist (such as salbutamol) given as soon as possible.

• For children with acute severe or life-threatening symptoms, administration via an oxygen-driven nebuliser is recommended, if available.

• Parents/carers of children with acute asthma at home, should seek urgent medical attention if initial symptoms are not controlled with up to 10 puffs of salbutamol via a spacer; if symptoms are severe, additional bronchodilator doses should be given as needed whilst awaiting medical attention.

• Urgent medical attention should also be sought if a child's symptoms return within 3-4 hours; if symptoms return within this time, a further or larger dose (maximum of 10 puffs of salbutamol via a spacer) should be given whilst awaiting medical attention.

• In all cases of acute asthma, children should be prescribed an adequate dose of oral prednisolone. Treatment for up to three days is usually sufficient, but the length of the course should be tailored to the number of days necessary to bring about recovery.

• Repeat the dose in children who vomit, and consider the intravenous route in those who are unable to retain oral medication.

• It is considered good practice that inhaled corticosteroids are continued at their usual maintenance dose whilst receiving additional treatment for the attack, but they should not be used as a replacement for the oral corticosteroid.

• Nebulised ipratropium bromide can be combined with a nebulised beta₂ agonist for children with a poor initial response to beta₂ agonist therapy to provide greater bronchodilation.

• Consider adding magnesium sulfate (unlicensed use) to each nebulised salbutamol and ipratropium bromide in the first hour in children with a short duration of severe acute asthma symptoms presenting with an oxygen saturation less than 92%.

• Children with continuing severe acute asthma despite frequent nebulised beta₂ agonists and ipratropium bromide plus oral corticosteroids, and those with life-threatening features, need urgent review by a specialist with a view to transfer to a high dependency unit or paediatric intensive care unit (PICU) to receive second-line intravenous therapies.

• In children who respond poorly to first-line treatments, intravenous magnesium sulfate (unlicensed use) may be considered as first-line intravenous treatment. In a severe asthma attack where the child has not responded to initial inhaled therapy, early addition of a single bolus dose of intravenous salbutamol may be an option.

• Continuous intravenous infusion of salbutamol, administered under specialist supervision with continuous ECG and electrolyte monitoring, should be considered in children with unreliable inhalation or severe refractory asthma.

• Intravenous aminophylline may be considered in children with severe or life-threatening acute asthma unresponsive to maximal doses of bronchodilators and corticosteroids.

NICE recommendations for management in children aged under 2 years

• Acute asthma treatment for all children aged under 2 years should be given in the hospital setting. Treatment of children aged under 1 year should be under the direct guidance of a respiratory paediatrician.

• For moderate and severe acute asthma attacks, immediate treatment with oxygen via a tight-fitting face mask or nasal prongs should be given to achieve normal SpO₂ saturations of 94-98%. Trial an inhaled short-acting beta₂ agonist and if response is poor, combine nebulised ipratropium bromide to each nebulised beta₂ agonist dose.

• Consider oral prednisolone daily for up to three days, early in the management of severe asthma attacks.

• In children not responsive to first-line treatments or have life-threatening features, discuss management with a senior paediatrician or the PICU team.

Current evidence does not support increasing the dose of inhaled corticosteroids (ICS) as part of a self-initiated action plan to treat exacerbations in children with mild-to-moderate asthma. Increased ICS dose is not associated with a statistically significant reduction in the odds of requiring rescue oral corticosteroids for the exacerbation, or of having adverse events, compared with a stable ICS dose.³

Follow-up ¹⁴

• Episodes of acute asthma may be a failure of preventative therapy. Therefore review is required to prevent further episodes.

• A careful history should be taken to establish the reason for the asthma attack.

• Inhaler technique should be checked and regular treatment should be reviewed.

• Parents should be given a written asthma action plan aimed at preventing relapse, optimising treatment, and preventing delay in seeking assistance in future attacks.

• It is essential that the GP practice is informed within 24 hours of discharge from the emergency department or hospital following an asthma attack, and the patient be reviewed by their GP within two working days.

• Any child who has had a near-fatal asthma attack should be kept under specialist supervision indefinitely.

• A respiratory specialist should follow up all children admitted with a severe asthma attack for at least one year after the admission.

Chronic asthma in children

It is very important to consider the upper respiratory tract when treating asthma. It is much more difficult to treat asthma successfully if co-existing allergic rhinitis (perennial or seasonal) is not adequately controlled.⁵

Non-drug treatment for chronic asthma in children¹

• NICE guidance on air quality at home recommends:⁶

  • Inclusion of approaches to minimising indoor air pollution and reducing exposure to outdoor air pollution personalised action plans.

  • Advice to patients on the role of indoor air pollutants - including nitrogen dioxide, damp, mould, particulate matter and volatile organic compounds (VOCs) - in triggering or exacerbating asthma.

  • Consideration of housing as a possible cause of cough or wheeze and, if relevant, assistance to patients/parents in requesting a housing assessment from the local authority.

  • Patients whose asthma is triggered by household sprays, air fresheners or aerosols should be advised to avoid them and use non-spray alternatives.

• Allergen avoidance - commonly recommended in patients with asthma but there is a lack of good evidence showing its efficacy:⁷

  • House dust mite - a Cochrane review concluded that chemical and physical methods of house dust mite avoidance could not currently be recommended.⁸ However, some families are very committed to trigger avoidance and suggestions can include:

    • Complete bed-covering barrier systems.

    • Removing all carpets.

    • Removing soft toys from the bed.

    • High-temperature washing of bed linen.

    • Acaricides to soft furnishings.

    • Improving ventilation with or without dehumidification.

  • Pet allergy - there are no controlled trials looking at removing domestic pets. There is varied anecdotal evidence with some experiencing no benefit on removing the pet and others, with continuing exposure to the pet, developing some tolerance. However, it seems sensible not to have a cat or dog if someone in the family already has asthma.

• Dietary manipulation - studies looking at supplementation with vitamin C, vitamin E, magnesium and fish oil have not shown significantly beneficial effects.⁹

• Complementary and alternative therapies:

  • There is insufficient evidence to recommend acupuncture, herbal or Chinese medicines, homeopathy, hypnosis or relaxation therapies.

  • Air ionisers offer no benefit to the treatment of asthma.

• Smoking cessation advice to caregivers and teenagers with asthma. Direct or passive smoking reduces lung function and increases the need for rescue medication and long-term 'preventer' treatment.

• Physical exercise therapy - may increase overall fitness but is of no specific benefit to asthma.

• Family therapy - where asthma is difficult to control, this may be a useful adjunct.

• Patient/carer education with the aim of creating partnership with family and child and confident self-care.

• Written asthma action plans for self-management lead to consistently improved outcomes.¹⁰

• Consider care links - for example, to school and transition to adult services. Schools should have their own asthma policy; staff are not required to administer asthma drugs except in an emergency but most are supportive of children with asthma and receptive to training in managing asthma and the correct way to administer inhaled drugs.

• Links to local and national patient groups for support and information.

Drug treatment for chronic asthma in children⁴

Current national guidelines advocate a stepwise approach. Start at the step most appropriate to the initial severity of symptoms. Aim to achieve early control and then decrease treatment by stepping down to the lowest controlling step once stable. Always check concordance and reconsider the diagnosis if response to treatment is poorer than anticipated.

NICE pharmacological treatment pathway for children aged 5 to 11⁴

• Offer a twice-daily paediatric low-dose inhaled corticosteroid (ICS), with an as-needed short-acting beta₂ agonist (SABA) for newly diagnosed asthma.

  • SABA-only monotherapy should no longer be used for asthma, in contrast with previous guidelines.

• If asthma is not controlled by this, consider maintenance and reliever therapy (MART) if the child is able to manage a MART regimen.

  • Begin with a low-dose formeterol/ICS inhaler (low-dose MART).

  • If low-dose MART does not achieve good asthma control, escalate to moderate-dose MART.

  • At the time of writing, no inhalers were licensed in the UK for MART in under-12s, so these would be prescribed off-license.

• If MART is not suitable:

  • Consider adding a leukotriene receptor antagonist (LTRA) to low-dose ICS plus SABA as needed. Use this for a trial period of 8 to 12 weeks, and stop if it is ineffective.

  • Increase therapy to a twice-daily paediatric ICS/long acting beta agonist (LABA) combination inhaler, plus SABA as needed (with or without a LTRA, depending on treatment response to this).

  • If low-dose ICS/LABA therapy plus SABA as needed does not achieve sufficient asthma control, increase to moderate-dose ICS/LABA plus SABA as needed (with or without a LTRA).

• If asthma control is not achieved with moderate-dose MART or moderate dose ICS/LABA plus SABA as needed, refer to an asthma specialist.

NICE pharmacological treatment pathway for children under 5

• It can be difficult to confirm asthma diagnosis in young children, therefore the following recommendations apply only to children with suspected or confirmed asthma. Asthma diagnosis should be confirmed when the child is able to undergo objective tests.

• Consider an 8 to 12 week trial of twice daily paediatric low-dose ICS as maintenance therapy and as-needed SABA for reliever therapy in children under 5 with suspected asthma and:

  • Symptoms at presentation that indicate maintenance therapy is necessary (for example, interval symptoms in children with atopy), or:

  • Severe acute episodes of difficulty breathing and wheeze (for example, requiring hospital admission, or needing 2 or more courses of oral corticosteroids).

• If symptoms do not resolve during this trial period:

  • Check inhaler technique and adherence.

  • Check whether there is an environmental cause of symptoms (for example, mould at home, cold housing, smokers, indoor air pollution).

  • Consider if an alternative diagnosis is likely.

  • If none of the above explain the failure of treatment response, refer the child to an asthma specialist.

• If symptoms resolve, consider stopping the ICS and SABA after 8 to 12 weeks, and review symptoms after a further 3 months.

• If symptoms resolve during the trial period, but either recur by the 3 month review, or the child has an acute episode requiring systemic corticosteroids or hospitalisation:

  • Restart regular ICS (starting at low dose and titrating up to moderate dose if needed) with as-needed SABA.

  • Consider a further trial without treatment within 12 months.

• If a moderate dose of ICS and as-needed SABA does not control suspected asthma symptoms, consider an 8 to 12 week trial of an LTRA in addition to the ICS.

• If the LTRA trials has been unsuccessful or was not tolerated, and asthma symptoms remain uncontrolled, refer to an asthma specialist.

Management of those aged over 12 years is as for adults. See the separate Management of Adult Asthma article.

Biologics^{11 1213}

Three biologics are approved for asthma treatment in children:

• Dupilumab (Dupixent) - for ages 12 and over.

• Omalizumab (Xolair) - for ages 6 and over.

• Tezepelumab (Tezspire) - for ages 12 and over.

These may be initiated and provided by asthma specialists for children with severe asthma. The exact criteria for use, as per NICE, differ slightly between medications, but in general are recommended as add-on treatments to optimised standard therapy where symptoms are still poorly controlled - for example, requiring multiple courses of oral corticosteroids, or continuous use of oral corticosteroids.

Referral^{1 4}

Indications for specialist referral in children include:

• Referral for tests not available in primary care.

• Diagnosis unclear.

• Poor response to monitored initiation of asthma treatment (see treatment pathways above).

• Severe/life-threatening asthma attack.

• ‘Red flags’ and indicators of other diagnoses:

  • Failure to thrive.

  • Unexplained clinical findings (for example, focal signs, abnormal voice or cry, dysphagia, inspiratory stridor).

  • Symptoms present from birth or perinatal lung problem.

  • Excessive vomiting or possetting.

  • Severe upper respiratory tract infection.

  • Persistent wet or productive cough.

  • Family history of unusual chest disease.

  • Nasal polyps.

• Parental concern or need for reassurance.

Consider referral for specialist assessment if a child repeatedly cannot perform objective tests and is not responding to treatment.

Immunisation¹⁴

Influenza vaccine - children with asthma who require continuous or repeated use of inhaled/systemic steroids or with previous exacerbations requiring hospital admission should be given the influenza vaccine.

However, influenza vaccine should be offered to all children who are not otherwise in a clinical risk group but who are eligible for vaccination as part of the ongoing phased roll out of the extension of the programme to all children aged 2 to less than 17 years old.

If children receive repeated systemic steroids sufficient to cause immunosuppression they also require pneumococcal vaccination.

Drug delivery devices^{1 15 16}

See the separate Which device in asthma? and Nebulisers in general practice articles.

• A metered dose inhaler (MDI) plus spacer device is the first-line choice for the delivery of ICS therapy in those aged over 5 years.

• Older children (usually from age 11 or 12) may be able to use a dry powder inhaler (DPI), which is less bulky than an MDI and spacer, and may be preferred.

• Where poor compliance with MDI and spacer is likely to jeopardise good asthma control, alternative devices should be considered whilst still looking to minimise systemic absorption.

• For those aged less than 5 years, corticosteroid and bronchodilator therapy should be delivered via MDI/spacer and face mask combination. Nebulisers may be considered where MDIs and spacers are not effective or if the child's clinical condition is poor.

• Children and their carers need to be trained in the use of their chosen device prior to prescribing and should be suitability reviewed looking at compliance and technique.

Complications of asthma in children

• Reduced quality of life.

• Reduced growth, usually as a result of poor control rather than treatment.

• Psychological morbidity - although differences appear to be the result of poor health rather than asthma itself.¹⁷

• Absence from school and educational disadvantage.

Prognosis²

• The earlier the onset of asthma, the better the prognosis. Most children who present under 2 years of age become asymptomatic by 6-11 years of age.

• Early-onset asthma in atopic children may be associated with a worse prognosis.

• The Melbourne Epidemiological Study of Childhood Asthma (a 1964-1999 longitudinal study) found that in most children with asthma, significant wheezing continued into adult life. The more severe or frequent symptoms were in childhood, the more likely it was that symptoms would continue into adulthood.

• One longitudinal analysis found that half of the children with severe asthma no longer had severe asthma after three years. There was a stepwise decrease in the proportion meeting severe asthma criteria.¹⁸