Asthma Management Handbook

Reviewing initial treatment in children 0–5 years


When prescribing any preventer medicine for a child, consider each treatment adjustment as a treatment trial: monitor response continually, review within 4 weeks, and adjust treatment according to response.

Figure. Stepped approach to adjusting asthma medication in children Opens in a new window Please view and print this figure separately:

Table. Reviewing and adjusting preventer treatment for children aged 0–5 years Opens in a new window Please view and print this figure separately:

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1
  • National Asthma Council Australia, 2010 2
  • Brand et al. 2008 3

If symptoms have been well controlled for at least 3 months in a child taking regular inhaled corticosteroid treatment, reduce the dose to find the minimal dose needed to control symptoms.

Table. Definitions of ICS dose levels in children

Inhaled corticosteroid

Daily dose (mcg)



Beclometasone dipropionate


>200 (up to 400)



>400 (up to 800)



>160 (up to 320)

Fluticasone propionate


>200 (up to 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


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:

Asset ID: 21

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1
  • Brand et al. 2008 3

If symptoms are well controlled for at least 3 months on the lowest available inhaled corticosteroid dose, consider the following options:

  • Stop preventer treatment completely, while monitoring the response, to judge whether symptoms have resolved.
  • Replace inhaled corticosteroid with a trial of montelukast or a cromone. If well controlled for a further 3 months, stop preventer treatment and monitor the response.
  • Advise parents about potential adverse psychiatric effects of montelukast

Figure. Stepped approach to adjusting asthma medication in children Opens in a new window Please view and print this figure separately:

Table. Reviewing and adjusting preventer treatment for children aged 0–5 years Opens in a new window Please view and print this figure separately:

How this recommendation was developed


Based on clinical experience and expert opinion (informed by evidence, where available), with particular reference to the following source(s):

  • van Asperen et al. 20101
  • Brand et al. 20083

If symptoms are not controlled, consider whether they may be due to a comorbidity or alternative diagnosis such as rhinosinusitis or suppurative lung disease.

How this recommendation was developed


Based on clinical experience and expert opinion (informed by evidence, where available).

If cough is the predominant symptom, carefully reassess the diagnosis before changing treatment. Do not use inhaled corticosteroids specifically for cough. Refer to national guidelines for diagnosis and management of cough. 

How this recommendation was developed

Adapted from existing guidance

Based on reliable clinical practice guideline(s) or position statement(s):

  • van Asperen et al. 2010 1
  • Gibson et al. 2010 4

More information

Approaches to assessment and monitoring of asthma control in children

Assessment of asthma control in children is based mainly on recent asthma symptom control (assessed by the frequency and severity of symptoms between flare-ups and the degree to which asthma symptoms affect daily activities such as interference with physical activity or missed school days), the frequency of flare-ups, and spirometry in children who are able to perform the test reliably.

Parents commonly underestimate the severity of their child's asthma and overestimate asthma control.5

Standardised questionnaires

Questionnaire-based instruments have been validated for assessing asthma control in children:

Measures of airway inflammation

Measures of airway inflammation (e.g. sputum test, exhaled nitric oxide) are not used in clinical practice to guide treatment decisions. Tailoring the dose of inhaled corticosteroids based on exhaled nitric oxide appears to achieve only a small benefit in children, and may lead to higher doses.11 

Administration of inhaled medicines in children: 0–5 years

To use inhaler devices correctly, parents and children need training in inhaler technique and in the care and cleaning of inhalers and spacers.

Children need careful supervision when taking their inhaled medicines (e.g. at preschool), especially when using a reliever for acute asthma symptoms. 

During acute wheezing episodes, delivery of short-acting beta2 agonist to airways is more effective with a pressurised metered-dose inhaler plus spacer than with a nebuliser.3 In older children, salbutamol has also been associated with a greater increase in heart rate when delivered by nebuliser than when delivered by pressurised metered-dose inhaler plus spacer.12

Dry-powder inhalers are usually ineffective for preschool children because they cannot generate sufficient inspiratory air flow.3

Preschool children cannot use pressurised metered-dose inhalers properly unless a spacer is attached (with mask when necessary), because it is difficult for them to coordinate inspiratory effort with firing the device.3 Note that breath-actuated pressurised metered-dose inhalers cannot be used with a spacer.

Even when using pressurised metered dose inhalers and spacers, drug delivery is very variable in young children.13 The inhaler design may improve spacer technique,13 but will not necessarily improve clinical outcomes. The amount of medicine delivered by inhaler devices to the lower airways varies from day to day in preschool children.3 This variation might explain fluctuations in effectiveness, even if the child’s parents have been trained to use the device correctly.

When administering salbutamol to relieve asthma symptoms in a preschool child, the standard recommendation is to shake the inhaler, fire one puff at a time into the spacer and have the child take 4–6 breaths in and out of the spacer (tidal breathing).14 Fewer breaths may suffice; in children with asthma aged 2–7 years (not tested during an acute asthma episode), the number of tidal breaths needed to inhale salbutamol adequately from a spacer has been estimated at 2 breaths for small-volume spacers, 2 breaths for a spacer made from a 500-mL modified soft drink bottle, and 3 breaths for a large (Volumatic) spacer.15

When using a spacer with face mask (e.g. for an infant too young or uncooperative to be able to use a mouthpiece), effective delivery of medicine to the airways depends on a tight seal around the face. When masks are used for inhaled corticosteroids, there is a risk of exposure to eyes and skin if the seal over the mouth and nose is not adequate. Parents should be advised to wash the child's face after administering inhaled corticosteroids by mask.

Babies are unlikely to inhale enough medicine while crying.12 The use of a spacer and face mask for a crying infant may require patience and skill: the child can be comforted (e.g. held by a parent, in own pram, or sitting on the floor) while the mask is kept on, and the actuation carefully timed just before the next intake of breath. Most infants will tolerate the spacer and mask eventually. The child may be more likely to accept the spacer and mask if allowed to handle them first (and at other times), if the devices are personalised (e.g. with stickers), or if the mask has a scent associated with the mother (e.g. lip gloss). The use of a spacer with a coloured valve allows parents to see the valve move as the child breathes in and out.

Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.1617

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,18, 19, 20, 21, 22 even among regular users.23 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.24

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.18, 25, 23, 26, 27 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.23

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.28, 29

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:24

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:24

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.24 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.30, 18, 31, 32 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.31 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).16, 29

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.28, 18, 19 

Managing cough in children

When cough is the predominant symptom in a young child, careful assessment is needed to avoid making an incorrect diagnosis of asthma, or instigating inappropriate treatment.4 Cough alone (recurrent non-specific cough) is most likely due to recurrent viral bronchitis, which is unresponsive to both bronchodilators and preventive therapy including inhaled corticosteroids. Recurrent non-specific cough usually resolves by age 6 or 7 years and leaves no residual pulmonary pathology.

If cough is a problem for a child with known asthma, it should be managed according to national Cough in Children and Adults: Diagnosis and Assessment (CICADA) guidelines.4

  • There are significant concerns about use of cough medicines in children.
Montelukast for children: warning parents about potential psychiatric adverse effects

Montelukast is generally very well tolerated.1 However, post-marketing surveillance reports suggested a slight increase in the rate of psychiatric disorders that was possibly associated with use of leukotriene receptor antagonists in children;33 this association may have been confounded by asthma severity and concomitant medication.1 Montelukast use has also been associated with suicidal ideation, but a recent nested case-control study concluded that children with asthma aged 5–18 years taking leukotriene receptor antagonists were not at increased risk of suicide attempts.34 Behavioural and psychiatric adverse effects were rare in clinical trials.35,36

A recent analysis of databases of adults and children taking montelukast suggests it is associated with nightmares, depression, and aggression.37 Allergic granulomatous angiitis has also been reported, but a causal relationship has not been established.37

The Thoracic Society of Australia and New Zealand advises that it is prudent to mention to parents the potential association of montelukast with behaviour-related adverse events when commencing treatment, and to cease therapy if such adverse events are suspected.1



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