Asthma - paediatric treatment guidance

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.

Intermittent reliever therapy

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

Regular preventer therapy

Inhaled corticosteroids (ICS) should be considered for children with any of the following features:

  • using inhaled beta2 agonist 3 times a week or more
  • symptomatic 3 times a week or more
  • waking with symptoms one night a week
  • an exacerbation requiring oral corticosteroid in the last two years

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:

  • using inhaled beta2 agonist 3 times/week or more

For children under 5, steroids should be discontinued if there is no change in symptoms after 2 months.

See section 3.2 Corticosteroids, 3.3.2 Leukotriene receptor antagonists (LTRAs)

Initial add-on preventer 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).

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.

Children under 2 years

Consider referral to secondary care

Children 2 – 5 years

In children less than 5 years of age a leukotriene receptor antagonist (LTRA) can be considered as initial add on therapy.

Children aged 5 – 12 years

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 should not be prescribed without ICS preventer treatment. Combination LABA/ICS devices are recommended to ensure LABA is given with appropriate ICS dose.

See section 3.1.4 Combination inhalers, 3.3.2 Leukotriene receptor antagonists (LTRAs)

Additional add-on therapies

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 there is no improvement when a LABA is added, stop the LABA and try:
    • an increase to low-dose of ICS, (total beclometasone 400 micrograms daily or equivalent), if not already on this dose
  • If there is an improvement when a LABA is added but control remains inadequate:
    • continue the LABA and increase to low dose of ICS (using a combination inhaler), (total beclometasone 400 micrograms daily or equivalent), or
    • continue the LABA and the very low-dose ICS (combination inhaler) and consider a trial of a leukotriene receptor antagonist (LTRA)

If still symptomatic: Refer to secondary care

See section 3.1.4 Combination inhalers, 3.2 Corticosteroids, 3.3.2 Leukotriene receptor antagonists (LTRAs)

High-dose therapies

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:

  • increase the ICS to medium dose, (total beclometasone 800 micrograms daily or equivalent) or
  • add a leukotriene receptor antagonist (LTRA) or
  • add a theophylline modified release

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.

See section 3.1.1 Adrenoceptor agonists, 3.1.3 Theophylline, 3.1.4 Combination inhalers, 3.2 Corticosteroids, 3.3.2 Leukotriene receptor antagonists (LTRAs)

Continuous or frequent use of oral steroids

Before proceeding to continuous or frequent use of oral steroid therapy, refer children with inadequately controlled asthma, to specialist care.

  • Use daily oral steroid in the lowest dose providing adequate control
  • Maintain medium dose therapy (beclometasone 800 micrograms/day or equivalent)
  • Consider other treatment options to minimise need for oral steroids

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.

Omalizumab (secondary care only) 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: Omalizumab for treating severe persistent allergic asthma

See section 3.4.2 Allergen Immunotherapy, 6.3.2 Glucocorticoid therapy

Stepping down therapy

Patients should be maintained at the lowest possible dose of inhaled corticosteroid (ICS), which provides control.

  • Discuss with the person (or their family or carer if appropriate) the potential risks and benefits of decreasing maintenance therapy.
  • Agree with the person (or their family or carer if appropriate) how the effects of decreasing maintenance therapy will be monitored and reviewed, including self-monitoring and a follow-up with a healthcare professional.
  • Consider decreasing maintenance therapy when a person's asthma has been controlled with their current maintenance therapy for at least 3 months.
  • Decrease the dose of ICS by approximately 25-50% each time.
  • Take symptom severity, treatment side effects, and time on current dose, benefit gained and patient preference into account when deciding which drug to step down and at what rate.
  • Some children with milder asthma and a clear seasonal pattern to their symptoms may have a more rapid dose reduction during their 'good' season.
  • Regular review of patients as treatment is stepped down is important.

Review and update the person's asthma treatment plan when decreasing maintenance therapy.

See section: 3.2 Corticosteroids

Acute asthma management

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:

  • 10 mg prednisolone for children under 2 years of age
  • 20 mg prednisolone for children aged 2–5 years
  • 30–40 mg prednisolone for children older than 5 years

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.

See section: 3.1.1 Adrenoceptor agonists, 6.3.2 Glucocorticoid therapy, 3.1.5 Peak flow meters, inhaler devices and nebulisers

Choice of device

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:

  • The availability of the drug and dose in the specific device.
  • The ability of the person to develop and maintain an effective technique with the specific device, this may depend on such factors as age, dexterity, coordination, and inspiratory flow. If the patient is unable to use a device satisfactorily an alternative should be found
  • Good technique is essential in ensuring the correct use of inhaler devices. Only prescribe inhalers after the person using them (or their carer) has received training in the use of the device and has demonstrated acceptable technique. Reassess inhaler technique as part of structured clinical review
  • Technique should be assessed by a competent healthcare professional
  • Inspiratory flow can be tested using, for example, an In-Check device.
  • The suitability of the device to the person's (and carer's) lifestyles, considering such factors as portability and convenience.
  • The person's preference for and willingness to use a particular device.
  • Choose the device with the lowest overall cost (taking into account daily required dose and product price per dose).
  • The medication needs to be titrated against clinical response to ensure optimum efficacy.

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.

Northern, Eastern and Western Devon Clinical Commissioning Group (NEW 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 NEW Devon CCG Medicines Optimisation Team, please contact: d-ccg.medicinesoptimisation@nhs.net

Monitoring, safety and side-effects

Monitor asthma control at every review.

If control is suboptimal:

  • Check for incorrect or additional, co-morbid - diagnosis
  • Confirm the person's adherence to prescribed treatment
  • Review the person's inhaler technique
  • Check the number of short acting beta2 agonists (SABAs) vs inhaled corticosteroids (ICS) being used
  • Review if treatment needs to be changed – check the suitability of current treatment
  • Consider psychosocial factors, and seasonal or environmental factors
  • Consider smoking (active and/or passive)

Concerns on any safety issue - refer to consultant paediatrician

  • Local side effects, e.g. oral thrush. Promote oral hygiene and rinsing after medication
  • Monitor growth - height and weight. Plot centiles and growth velocity
  • Review control and drug doses regularly (3-4 monthly)
  • Aim to use minimum doses and least complex treatments to control disease
  • Greater risk of side effects encountered at or above the following doses: beclometasone 400 micrograms/ day; budesonide 800 micrograms/ day; fluticasone 400 micrograms/ day
  • High doses at or above 800 micrograms per day of beclometasone equivalent carry a risk of adrenal insufficiency (reduced consciousness, hypoglycaemia) especially during non-respiratory intercurrent illness. Refer to paediatrician if patient on this dose. Must not stop medication abruptly. Steroid card and rescue plan (oral prednisolone 0.2mg/ kg/ day or IM injected hydrocortisone 4mg/ kg 6-8 hourly) are required
  • Consider the total steroid intake, including those taken for co-morbidities (e.g. allergic rhinitis)
  • Consider ophthalmology assessment for cataracts in children on long-term high dose steroids.

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.

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