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For children over 12 years of age refer to the adult treatment guidance.
It can be difficult to confirm asthma diagnosis in young children (children <5 years), therefore these recommendations apply to children with suspected or confirmed asthma. Asthma diagnosis should be confirmed when the child is able to undergo objective tests.
The guidance below is in line with that produced by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidance Network (SIGN).
Treatment Plan: Asthma treatment in children should be supported by a parent-held written treatment plan. Asthma UK has produced a plan specifically for use in Children.
Trial any change of therapy involving an inhaled corticosteroid (ICS) for at least 6 weeks. Full control may take 3-6 months to achieve. Other therapy changes may show improvement in less than 6 weeks.
Step up asthma treatments to improve control as needed; step down to find and maintain lowest controlling step.
Be mindful of overuse of reliever Inhalers. All asthma patients who have been prescribed more than 6 short-acting reliever inhalers in the previous 12 months should be considered for a review. Those patients prescribed more than 12 short-acting reliever inhalers in the previous 12 months should be invited for urgent review as this is associated with an increased risk of asthma death (NRAD, 2014). Medicines adherence, inhaler technique and self-management plans should be considered, and changes made to the patient's treatment if required.
Different products and doses are licensed for different age groups and some may be applicable only to older children or adults (aged 18 years and over). Prior to prescribing, the relevant summary of product characteristics (SPC) should be checked.
Children with a diagnosis of asthma should be prescribed a short-acting bronchodilator to relieve symptoms. For those with infrequent short-lived wheeze, occasional use of reliever therapy may be the only treatment required.
Inhaled short acting beta2 agonists (SABA) as required
Many non-atopic children under five with recurrent episodes of viral-induced wheezing do not go on to have chronic atopic asthma. The majority do not require treatment with regular inhaled corticosteroid (ICS).
See section 3.1.1 Adrenoceptor agonists
Inhaled corticosteroids (ICS) should be considered for children with any of the following features:
ICS are the most effective preventer drug for adults and older children for achieving overall treatment goals. There is an increasing body of evidence demonstrating that, at recommended doses, they are also safe and effective in children under five with asthma. Children with a diagnosis of asthma should be prescribed a short-acting bronchodilator to relieve symptoms (see intermittent reliever therapy).
Before initiating a new drug therapy, practitioners should check adherence with existing therapies, check inhaler technique and spacer use, and eliminate trigger factors (see Monitoring, safety and side-effects below)
In mild to moderate asthma, a reasonable starting dose, taken twice a day, of ICS will usually be very low (paediatric) dose (total beclometasone 200 micrograms/day or equivalent) for children. Starting at high doses of ICS and stepping down confers no benefit. Start patients at a dose of inhaled corticosteroids appropriate to the severity of disease.
Most ICS are slightly more effective when taken twice rather than once daily, but may be used once daily in some patients with milder disease and good or complete control of their asthma.
In children under five years who are unable to take ICS, leukotriene receptor antagonists (LTRA) may be used as an alternative preventer.
Consider initial add-on preventer therapy, if:
For children under 5, steroids should be discontinued if there is no change in symptoms after 2 months.
Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique and spacer use, and eliminate trigger factors (see Monitoring, safety and side-effects below).
Not all brands & strengths of inhaled corticosteroids (ICS) / long-acting beta 2 agonist (LABA) inhalers are licenced for use in people aged under 18 years; consult the manufacturer's Summary of Product Characteristics (SPC) for full licensing information.
Consider referral to secondary care
In children less than 5 years of age a leukotriene receptor antagonist (LTRA) can be considered as initial add on therapy.
In children aged 5 - 12 years an inhaled LABA can be considered as initial add on therapy, or LTRA.
In asthma, do not prescribe a LABA without ICS preventer treatment. Combination LABA/ICS devices are recommended to ensure LABA is given with appropriate ICS dose.
If control remains poor on very low-dose inhaled corticosteroid (ICS) plus a long-acting beta 2 agonist (LABA) combination inhaler, recheck the diagnosis, assess adherence to existing medication and check inhaler technique and spacer use, before increasing therapy. If more intense treatment is appropriate, then the following alternatives can be considered.
If still symptomatic: Refer to secondary care
If still symptomatic: Refer to secondary care
Medium dose inhaled corticosteroid (ICS) (total beclometasone 800 micrograms daily or equivalent) should only be used after referring the patient to secondary care.
Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique and spacer use, and eliminate trigger factors (see Monitoring, safety and side-effects below)
If control remains inadequate on low-dose of an ICS (total beclometasone 400 micrograms daily or equivalent), plus a long-acting beta 2 agonist (LABA), the following interventions can be considered:
If a trial of an add-on treatment is ineffective, stop the drug (or in the case of increased dose of ICS, reduce to the original dose).
Children (all ages) who are under specialist care may benefit from a trial of higher doses ICS (greater than 800 micrograms daily) before moving to use of oral steroids.
Children on these doses of ICS need to carry a steroid card to include a rescue plan for steroid replacement therapy during non-respiratory intercurrent illness.
Before proceeding to continuous or frequent use of oral steroid therapy, refer children with inadequately controlled asthma, to specialist care.
Patients on long-term steroid tablets (for example, longer than three months) or requiring frequent courses of steroid tablets (for example three to four per year) will be at risk of systemic side effects, monitoring may be required.
See section 6.3.2 Glucocorticoid therapy
The following treatments may be recommended for use in secondary care:
Omalizumab is recommended as an option for treating severe persistent confirmed allergic IgE mediated asthma as an add on to optimised standard therapy in people aged 6 years and older. See NICE TA278 (April 2013)
3.4.2 Allergen Immunotherapy,
Patients should be maintained at the lowest possible dose of inhaled corticosteroid (ICS), which provides control.
Review and update the person's asthma treatment plan when decreasing maintenance therapy.
See section: 3.2 Corticosteroids
Guidance regarding when to start acute asthma treatment should be detailed in the written management plan, with advice to seek a medical review when treatment begins.
Inhaled beta 2 agonists are the first-line treatment for acute asthma in children. A pressurised metered dose inhaler + spacer is the preferred option for children with mild to moderate asthma. Children less than three years of age are likely to require a face mask connected to the mouthpiece of a spacer for successful drug delivery.
Two to four puffs of salbutamol (100 micrograms via a pressurised metered dose inhaler + spacer) might be sufficient for mild asthma attacks, although up to 10 puffs might be needed for more severe attacks. Single puffs should be given one at a time (every 30-60 seconds) into the spacer and inhaled separately with five tidal breaths. Relief from symptoms should last 3–4 hours. If symptoms return within this time a further or larger dose (up to a maximum of ten puffs) should be given and the parents/ carer should seek urgent medical advice.
If symptoms are severe additional doses of bronchodilator should be given as needed whilst awaiting medical attention.
Children with severe or life-threatening asthma should receive frequent doses of nebulised bronchodilators driven by oxygen.
Oral steroids should be given early in the treatment of acute asthma attacks in children. Once daily oral prednisolone is the steroid of choice for asthma attacks in children unless the patient is unable to tolerate the dose:
Those already receiving maintenance steroid tablets should receive 2 mg/kg prednisolone up to a maximum dose of 60 mg.
Repeat the dose of prednisolone in children who vomit and consider intravenous steroids in those who are unable to retain orally ingested medication.
Treatment for up to three days is usually sufficient, but the length of course should be tailored to the number of days necessary to bring about recovery. Tapering is unnecessary unless the course of steroids exceeds 14 days.
Note: children under 5 with viral trigger are unlikely to benefit from steroids.
Rescue medication/emergency supply: Patients who have experienced severe attacks or who live in geographically isolated areas should have a standby rescue course of oral prednisolone as per doses above.
Before considering therapy changes, check inhaler technique and compliance with therapy. A Pressurised Metered Dose Inhaler (pMDI), with or without a spacer, is the first choice delivery device. Consider alternatives if compliance and/or technique problems effect control.
A face mask is required until the child can breathe reproducibly using the spacer mouthpiece. Where this is ineffective a nebuliser may be required (see Nebulisation guidance).
When choosing an inhaler device consider:
Generic prescribing of inhalers should be avoided as this might lead to people with asthma being given an unfamiliar inhaler device which they are not able to use properly.
Prescribing mixed inhaler types may cause confusion and lead to increased errors in use. Using the same type of device to deliver preventer and reliever treatments may improve outcomes.
The NHS Devon CCG Medicines Optimisation Team has produced a webpage which provides further respiratory information for patients and healthcare professionals; this information can be found here, and includes guides to inhaler techniques and checklists.
Advice on how to obtain placebo inhalers can be obtained from the NHS Devon CCG Medicines Optimisation Team, please contact: firstname.lastname@example.org
Monitor asthma control at every review.
If control is suboptimal:
Concerns on any safety issue - refer to consultant paediatrician
Children treated with medium or high dose ICS should be under the care of a specialist paediatrician for the duration of treatment. Specific written advice about steroid replacement in the event of a severe intercurrent illness should be part of the management plan.