Asthma Management Handbook

Managing asthma in children

Overview

Children aged 0–12 months

Wheezing infants aged less than 12 months old should not be treated for asthma. Wheezing in this age group is most commonly due to acute viral bronchiolitis or to small and/or floppy airways.

Advice should be obtained from a paediatric respiratory physician or paediatrician before administering short-acting beta2 agonists, systemic corticosteroids or inhaled corticosteroids to an infant under 12 months.

Children with clinically significant wheezing that necessitates hospitalisation or occurs frequently (e.g. more than once per 6 weeks) should be referred to a paediatric respiratory physician or paediatrician.

Children aged 1–5 years

Many infants and preschoolers wheeze when they have viral respiratory infections, even if they do not have asthma.

As-needed salbutamol should be used to relieve symptoms during wheezing episodes in children with wheezing that has been shown to be salbutamol-responsive in a treatment trial.

A small proportion of infants and preschoolers may also need regular preventer treatment for preschool wheeze (e.g. those who have recurrent symptoms between viral respiratory infections.)

Table. Classification of preschool wheeze and indications for preventer treatment in children aged 1–5

Severity of flare-ups

Frequency of symptoms

Symptoms every 6 months or less

Symptoms every 3–4 months

Symptoms every 4–6 weeks

Symptoms at least once per week

Mild flare-ups

(managed with salbutamol in community)

Not indicated

Not indicated

Consider

Indicated

Moderate–severe flare-ups

(require ED care/oral corticosteroids)

Indicated

Indicated

Indicated

Indicated

Life-threatening flare-ups

(require hospitalisation or PICU)

Indicated

Indicated

Indicated

Indicated

PICU: paediatric intensive care unit; ED: emergency department

Indicated: Prescribe preventer and monitor as a treatment trial. Discontinue if ineffective.

Not indicated: Preventer is unlikely to be beneficial

Consider prescribing preventer according to overall risk for severe flare-ups

Symptoms: wheeze, cough or breathlessness. May be triggered by viral infection, exercise or inhaled allergens

Flare-up: increase in symptoms from usual day-to-day symptoms (ranging from worsening asthma over a few days to an acute asthma episode)

Preventer options: an inhaled corticosteroid (low dose) or montelukast

[!] Advise parents/carers about potential adverse behavioural and/or neuropsychiatric effects of montelukast

Notes:
Preventer medication is unlikely to be beneficial in a child whose symptoms do not generally respond to salbutamol

In children taking preventer, symptoms should be managed with a short-acting inhaled beta2 agonist reliever (e.g. when child shows difficulty breathing).

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Children aged 6 years and over

The diagnosis of asthma can be made with more certainty in school-aged children. In this age group, the presence of reversible expiratory airflow limitation on spirometry supports the diagnosis of asthma.

All school-aged children with asthma need a reliever to use when they have asthma symptoms.

Regular preventer treatment is indicated for those with frequent intermittent asthma (flare-ups every 6 weeks or more often) or persistent asthma symptoms (daytime asthma symptoms more than once per week or night-time symptoms more than twice per month) and those with severe flare-ups, irrespective of the frequency of flare-ups or symptoms between flare-ups.

Table. Classification of asthma and indications for initiating preventer treatment in children aged 6–11

 

 

 

 

 

 

Severity of flare-ups

Average frequency of flare-ups and symptoms between flare-ups

Infrequent intermittent
Flare-ups every 6 weeks or less and no symptoms between flare-ups

Frequent intermittent
Flare-ups more than once every 6 weeks and no symptoms between flare-ups

Persistent
Between flare-ups (any of):

  • Daytime symptoms‡ more than once per week
  • Night-time symptoms‡ more than twice per month
  • Symptoms restrict activity or sleep

Mild flare-ups

(almost always managed with salbutamol in community)

 

Not indicated

 

Consider

 

Indicated

Moderate–severe flare-ups

(>2 in past year requiring ED or oral corticosteroids)

 

Consider

 

Indicated

 

Indicated

Life-threatening flare-ups

(require hospitalisation or PICU)

 

Indicated

 

Indicated

 

Indicated

 

Preventer should be started as a treatment trial. Assess response after 4–6 weeks and review before prescribing long term.

ED: emergency department

Indicated: Prescribe preventer and monitor as a treatment trial. At follow-up, discontinue if ineffective

Not indicated: Preventer is unlikely to be beneficial

Consider prescribing preventer according to overall risk for severe flare-ups

‡ Symptoms between flare-ups. A flare-up is defined as a period of worsening asthma symptoms, from mild (e.g. symptoms that are just outside the normal range of variation for the child, documented when well) to severe (e.g. events that require urgent action by parents/carers and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).

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General principles of asthma treatment in children

Aim for good control of asthma symptoms

Try to identify what triggers asthma symptoms (e.g. allergens).

Manage comorbid conditions that affect asthma (e.g. allergic rhinitis).

Show parents and children (if old enough) when and how to take reliever medicine.

Monitor regularly and adjust the treatment regimen to maintain good control of symptoms and prevent flare-ups, while minimising the dose of inhaled corticosteroids (if needed).

Provide parents/carers and children with information and skills to manage their asthma, including:

  • a written asthma action plan to follow when symptoms worsen
  • information about reducing exposure to triggers, where appropriate (e.g. all tobacco smoke, but allergens only when likely to be helpful and cost-effective)
    See: Asthma triggers
  • training in correct use of medicines, including inhaler technique
  • information and support to maximise adherence.
  • advice about avoidance of tobacco smoke, healthy eating, physical activity, healthy weight and immunisation.

Table. Definition of levels of recent asthma symptom control in children (regardless of current treatment regimen)

Good control Partial control Poor control

All of:

  • Daytime symptoms ≤2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • No limitation of activities
  • No symptoms§ during night or when wakes up
  • Need for SABA reliever# ≤2 days per week

Any of:

  • Daytime symptoms >2 days per week (lasting only a few minutes and rapidly relieved by rapid-acting bronchodilator)
  • Any limitation of activities*
  • Any symptoms during night or when wakes up††
  • Need for SABA reliever# >2 days per week

Either of:

  • Daytime symptoms >2 days per week (lasting from minutes to hours or recurring, and partially or fully relieved by SABA reliever)
  • ≥3 features of partial control within the same week

SABA: short-acting beta2 agonist

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including doses taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

​* e.g. wheeze or breathlessness during exercise, vigorous play or laughing

†† e.g. waking with symptoms of wheezing or breathing problems

Notes:

Recent asthma control is based on symptoms over the previous 4 weeks. Each child’s risk factors for future asthma outcomes should also be assessed and taken into account in management.

Validated questionnaires can be used for assessing recent symptom control:
Test for Respiratory and Asthma Control in Kids (TRACK) for children < 5 years
Childhood Asthma Control Test (C-ACT) for children aged 4–11 years

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Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (microg)

Low

High

Beclometasone dipropionate

100–200

>200 (maximum 400)

Budesonide

200–400

>400 (maximum 800)

Ciclesonide

80–160

>160 (maximum 320)

Fluticasone propionate

100–200

>200 (maximum 500)

† Dose equivalents for Qvar (TGA-registered CFC-free formulation of beclometasone dipropionate)

‡ Ciclesonide is registered by the TGA for use in children aged 6 and over

Source

van Asperen PP, Mellis CM, Sly PD, Robertson C. The role of corticosteroids in the management of childhood asthma. The Thoracic Society of Australia and New Zealand, 2010. Available from: 
http://www.thoracic.org.au/clinical-documents/area?command=record&id=14

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Figure. Stepped approach to adjusting asthma medication in children aged 1-5 years Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/18

Figure. Stepped approach to adjusting asthma medication in children aged 6-11 years Opens in a new window Please view and print this figure separately: http://www.asthmahandbook.org.au/figure/show/120

 

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