Asthma - paediatric treatment guidance

For children over 12 years of age refer to the adult treatment guidance

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.

Rescue medication: Patients who have experienced severe attacks or who live in geographically isolated areas should have a standby rescue course of oral prednisolone (1-2mg/ kg/ day; maximum 40mg). When to start should be detailed in the written management plan with advice to seek a medical review when treatment begins.

Before considering therapy changes, check inhaler technique and compliance with therapy. A Metered Dose Inhaler (MDI), with or without a spacer, is the first choice delivery device. Consider alternatives if compliance and/or technique problems effect control.

Trial any change of therapy involving an inhaled corticosteroid (ICS) for at least 6 weeks. Once full control is achieved, which may take 3-6 months, consider stepping down (25-50% drop in dose of inhaled steroid) to lowest level that maintains control. Other therapy changes may show improvement in less than 6 weeks.

Move up to improve control as needed, move down to find and maintain lowest controlling step.

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.

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, with the aim of improving their asthma through education and change of treatment if required.

Step 1 - Mild intermittent asthma

Inhaled short acting beta2 agonists 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).

Consider moving to Step 2 if:

  • 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

See section: 3.1.1 Adrenoceptor agonists

Step 2 - Regular preventer therapy

Inhaled corticosteroids (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.

In mild to moderate asthma, a reasonable starting dose, taken twice a day, of inhaled corticosteroids will usually be very low (paediatric) dose (total beclometasone 200 micrograms daily or equivalent) for children. Starting at high doses of ICSs 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 may be used as an alternative preventer.

Consider initial add-on therapy, moving to Step 3 if:

  • using inhaled beta2 agonist 3 times/week or more

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

Step 3 - Add-on therapy

Before initiating a new drug therapy practitioners should check adherence with existing therapies, check inhaler technique, and eliminate trigger factors.

Not all brands & strengths of inhaled corticosteroid (ICS) / long-acting beta2 agonist (LABA) inhalers are licenced for use in young children; consult the appropriate SPC for full details of licence.

Childern under 2 years

Consider referral to secondary care.

Children aged 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, 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.

Additional add-on therapies

If control remains poor on low-dose ICS plus a LABA, recheck the diagnosis, assess adherence to existing medication and check inhaler technique 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, (total beclometasone 400 micrograms daily or equivalent), or
    • continue the LABA and the low-dose ICS and consider a trial of a LTRA
    • If on LTRA and inadequately controlled, reconsider addition of ICS.

If still symptomatic: Refer to secondary care

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

Step 4 - 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 eliminate trigger factors.

If control remains inadequate on low dose of an ICS (total beclometasone 400 micrograms daily or equivalent), plus a 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 or
  • add a theophylline modified release or

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)


Step 5 - Frequent exacerbations needing 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 high 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

Stepping down therapy

  • Patients should be maintained at the lowest possible dose of inhaled steroid. Consider if reduction is possible every three months, decreasing the dose by approximately 25-50% each time.
  • 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. 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.

Acute asthma exacerbation

Regular bronchodilators at home should not be administered more than 4 hourly without seeking immediate medical advice. Beyond this threshold, salbutamol can be administered repeatedly via nebuliser or 6-10 puffs via MDI and spacer every 20 minutes until medical review secured.

Systemic steroids should be administered at the earliest opportunity, prednisolone 1-2mg/ kg up to 40mg.

Choice of device

In children, a pMDI and spacer are the preferred method of delivery of beta2 agonists and inhaled corticosteroids. 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)

  • The choice of device may be determined by the choice of drug
  • If the patient is unable to use a device satisfactorily an alternative should be found
  • The patient should have their ability to use the prescribed inhaler device (particularly for any change in device) assessed by a competent healthcare professional
  • Inspiratory flow can be tested using, for example, an In-Check device.
  • The medication needs to be titrated against clinical response to ensure optimum efficacy.
  • Reassess inhaler technique as part of structured clinical review

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.

Monitoring, safety and side-effects

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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