Australian Asthma Handbook
The National Guidelines for Health Professionals
Australian Asthma Handbook
The National Guidelines for Health Professionals
Table
| Situation | Total dose per occasion | Administration |
| Cough or wheeze without visibly increased work of breathing | 2 actuations x salbutamol 100 microg/actuation If symptoms do not resolve within a few minutes, give 2 more actuations. | Administer via spacer (and mask, if needed) Add 1 actuation to spacer – child takes 4 breaths in and out of spacer. Immediately repeat for second and subsequent actuations until the recommended number of actuations have been given. |
| Symptoms with increased work of breathing | 6 actuations x salbutamol 100 microg/actuation If symptoms do not resolve within a few minutes, give 6 more actuations and call 000 for an ambulance. If symptoms still do not resolve, or recur within 3 hours, parents/carer should take child to ED or call 000 for an ambulance. |
Table
| Active ingredient | Total daily dose (microg) | |
| Low | Medium/high | |
| Fluticasone propionate | 100 (50 twice daily) | 200 (100 twice daily) |
Additional information
ICS: inhaled corticosteroid
Medium/high doses should be avoided except under specialist supervision
Provide clear instructions to parents/carers about salbutamol doses when symptoms do not rapidly resolve or recur within hours.
Educate parents on how to recognise an asthma emergency.
Ensure the child’s asthma action plan is kept up to date.
Recommendation type: Consensus recommendation
For more information see guidance on assessing and managing acute asthma in primary care or emergency departments.
Recommendation type: Consensus
For children not taking regular ICS treatment (ICS or ICS-LABA), do not prescribe short-term high-dose ICS to manage worsening asthma symptoms or as part of a written asthma action plan.
For children treated with maintenance low-dose ICS, do not prescribe short-term high-dose ICS to manage worsening asthma symptoms or as part of a written asthma action plan.
Recommendation type: Consensus recommendation
For preschool children with clinically significant wheezing episodes triggered by respiratory tract infections, but no signs/symptoms between exacerbations, maintenance treatment with a low dose of ICS is recommended based on overall efficacy and safety in this age group.
Short courses of high doses of ICS, commenced at the onset of emerging respiratory tract infections, have sometimes been recommended for children aged 1–5 years with wheezing episodes triggered by infections.[Jackson 2021, NAEPP 2020]
However, the evidence that this strategy may be effective in preventing symptoms progressing to a severe exacerbation requiring systemic corticosteroid treatment is from studies using daily doses far exceeding recommended doses for this age group and/or a non-recommended delivery device (nebuliser).[Jackson 2021, NAEPP 2020]
High doses should be avoided in young children, except under specialist supervision.
Jackson DJ, Bacharier LB. Inhaled corticosteroids for the prevention of asthma exacerbations. Ann Allergy Asthma Immunol 2021; 127: 524-529.
NAEPPCoordinating Committee Expert Panel Working Group. 2020 focused updates to the asthma management guidelines. National Asthma Education and Prevention Program, US National Heart, Lung and Blood Institute, Department of Health and Human Services: 2020.
In children aged 1–5 years, the use of oral corticosteroids should generally be restricted to acute care services.
The usual dose for children aged 1–5 years is 1 mg/kg prednisolone (maximum 50 mg) each morning for up to 3 days.
Recommendation type: Consensus recommendation
Prescribers should avoid supplying parents with more prednisone/prednisolone than needed for the course. Prescribers may write PBS scripts for less than the maximum quantity and number of repeats permitted if a lesser quantity is sufficient for the patient’s requirements.
For children aged 1–5 years, do not routinely instruct parents/carers to start a course of oral corticosteroids at their own discretion.
Do not routinely prescribe or recommend oral corticosteroids to be started at home as part of the child’s written asthma action plan.
Consensus recommendation
The use of short courses of oral corticosteroids initiated by parents to prevent worsening of asthma exacerbations in children is not adequately supported by clinical trial evidence.[Ganaie 2016]
The use of multiple short courses of oral corticosteroids to manage asthma exacerbations in children is associated with a dose-dependent reduction in bone mineral accretion and increased risk for osteopenia.[Kelly 2008] In adults, short courses of oral corticosteroids to manage asthma exacerbations are associated with increased lifetime risk of osteoporosis, pneumonia, cardiovascular or cerebrovascular diseases, cataract, sleep apnoea, renal impairment, depression/anxiety, type 2 diabetes, and weight gain.[Price 2018]
Anecdotal evidence suggests widespread overuse of oral corticosteroids in children in Australia, administered by parents in the belief that oral medicines are unlikely to be harmful.
Ganaie MB, Munavvar M, Gordon M, et al. Patient- and parent-initiated oral steroids for asthma exacerbations. Cochrane Database Syst Rev 2016; 12: CD012195.
Kelly HW, Van Natta ML, Covar RA, et al. Effect of long-term corticosteroid use on bone mineral density in children: a prospective longitudinal assessment in the childhood Asthma Management Program (CAMP) study. Pediatrics 2008; 122: e53-e61.
Price DB, Trudo F, Voorham J, et al. Adverse outcomes from initiation of systemic corticosteroids for asthma: long-term observational study. J Asthma Allergy 2018; 11: 193-204.
Victoria: Victorian Virtual Emergency Department
NSW: virtualKIDS Urgent Care Service via Healthdirect 1800 022 222
Queensland: Virtual Emergency Care Service - Queensland Virtual Hospital
Instruct parents to contact a health professional before starting a course of oral corticosteroid for their child. If the child’s GP or usual asthma clinician is unavailable, parents should contact the online or phone urgent care service in their state or territory.
Some asthma action plan templates include a checkbox for oral corticosteroid with typical dosing instructions. Strike out these instructions to avoid misunderstanding.
For children with severe asthma managed in specialist care, clinicians might instruct parents when to start oral corticosteroids.
Prescribers should avoid supplying parents with more prednisone/prednisolone than needed for the course. Prescribers may write PBS scripts for less than the maximum quantity and number of repeats permitted if a lesser quantity is sufficient for the patient’s requirements.
Provide clear instructions on the child’s written asthma action plan on when to start oral corticosteroids.
Instruct parents to report if oral corticosteroids are used.
When writing scripts for oral corticosteroids, do not allow repeats.
Recommendation type: Consensus recommendation
If feasible, instruct parents to get medical advice before starting the course of prednisone/prednisolone tablets or oral liquid.
Explain that this medicine is intended for emergencies, when the child has worsening breathing difficulty that is not resolved by salbutamol given as instructed in the child’s asthma action plan. Explain that it should not be started for day-to-day wheezing or given to another child.
Prescribers should avoid supplying parents with more prednisone/prednisolone than needed for the course. Prescribers may write PBS scripts for less than the maximum quantity and number of repeats permitted if a lesser quantity is sufficient for the patient’s requirements.
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