Asthma Management Handbook

Managing flare-ups in children 6 years and over

Recommendations

Ensure all children with asthma have a rapid-acting inhaled bronchodilator (reliever) inhaler with them at all times. Educate parents how and when to give reliever.

  • Do not prescribe oral salbutamol. Inhalation is the recommended route for delivering relievers for all children and adults.

Table. Non-emergency use of bronchodilators (relievers) in children aged 6–12 years

Option

Notes

Dose and delivery

Salbutamol

Suitable for children any age

A spacer should be used during acute flare-ups (exacerbations)

2–4 puffs (100 mcg per puff) via pressurised metered-dose inhaler and spacer

Terbutaline

Generally suitable for children 6 years and older

1–2 inhalations (500 mcg/inhalation) via breath-actuated powder inhaler

Note: This table lists usual doses to be administered by carers in the community to manage symptoms as needed. Doses are higher during acute asthma, including emergencies.

† If able to use this type of inhaler correctly

  • Do not prescribe oral salbutamol.

Asset ID: 28

Close
How this recommendation was developed

Consensus

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

Consider prescribing a short course of prednisolone for children with acute asthma if a beta2 agonist reliever (either of):

  • does not relieve symptoms for at least 4 hours
  • is needed approximately every 4 hours over a period of 24 hours.

Recommended dose: a single starting dose of 2 mg/kg (maximum 50 mg) orally, then 1 mg/kg once daily for 3 days.

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

If a child requires more than 4 courses of oral corticosteroids within a 12-month period, reassess the treatment regimen and consider specialist referral.

How this recommendation was developed

Consensus

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

  • van Asperen et al. 2010 1

Do not prescribe long-term oral corticosteroids without specialist assessment by a paediatric respiratory physician.

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

For all children using a regular preventer (montelukast, inhaled corticosteroid, or combination of inhaled corticosteroid plus long-acting beta2 agonist) explain to children and parents that the child should keep taking it during asthma flare-ups, including acute asthma episodes that require treatment in an emergency department. 

How this recommendation was developed

Consensus

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

Do not routinely prescribe antibiotics for children with upper respiratory tract infections who experience acute wheeze or asthma associated with infections, if antibiotics would not otherwise be indicated.

How this recommendation was developed

Selected evidence

Based on a limited structured literature review or published systematic review, which identified the following relevant evidence:

  • Graham et al. 2001 2
  • Fonseca-Aten et al. 2006 3
  • Schwerk et al. 2011 4
  • Johnston, 2006 5
  • Bush et al. 2011 6

More information

Short-acting beta-2 agonist relievers for children: 6 years and over

Inhaled short-acting beta2 agonists are the major class of bronchodilators used for relief of symptoms in asthma.7 They are the most effective bronchodilators available and are recommended by international guidelines for use in children of all ages as well as in adults.8

Children with controlled asthma need little or no reliever (on no more than 2 days per week).

Increased use of short-acting beta2 agonists for relief of asthma symptoms, especially daily use, indicates deterioration of asthma control.89

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 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 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 rapid-acting bronchodilator)
  • ≥3 features of partial control within the same week

† e.g. wheezing or breathing problems

‡ child is fully active; runs and plays without symptoms

§ including no coughing during sleep

# not including short-acting beta2 agonist 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

Note: 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.

Adapted from

Global Initiative for Asthma (GINA). Global strategy for the diagnosis and management of asthma in children 5 years and younger. GINA, 2009. Available from: http://www.ginasthma.org/

Asset ID: 23

Close
Close
Administration of inhaled medicines in children: 6 years and over

School-aged children (depending on the child’s age, ability, and with individualised training) can correctly use a range of inhaler types,10 including manually actuated pressurised metered-dose inhalers with spacers,11 breath-actuated pressurised metered-dose inhalers (e.g. Autohaler), and dry-powder inhalers (e.g. Accuhaler, Turbuhaler).1112

A pressurised metered-dose inhaler and spacer is an appropriate first choice for most children.10

Parents and children need training to use inhaler devices correctly, including inhaler technique, and care and cleaning of inhalers and spacers.

School-aged children are unlikely to use their inhaler device correctly without careful training.13

Close
Oral corticosteroids for children: 6 years and over

A short course of oral corticosteroid may be helpful in gaining rapid asthma control, with a low risk of additional systemic adverse effects.1

Rarely, long-term systemic corticosteroids may be needed for children with severe persistent asthma that is poorly controlled despite high-dose inhaled corticosteroids and long-acting beta2 agonists.1 However, significant adverse effects may occur due to recurrent or long-term systemic corticosteroids.1

Close
Parent-initiated oral corticosteroid treatment in children

There is limited and inconclusive evidence from clinical trials evaluating the effectiveness of courses of oral corticosteroids initiated by parents in response to children’s wheezing.14

In children aged 6–14 years, a course of oral prednisolone initiated by parents in response to an asthma flare-up may reduce asthma symptoms and the number of missed school days.15

In children aged 1–5 years with episodic wheezing, oral corticosteroids are not effective in managing the symptoms of acute lower respiratory tract illnesses.16

Close
Oral corticosteroids for children: adverse effects

A short course of oral corticosteroid therapy (less than 2 weeks) is associated with little risk of long-term suppression of the hypothalamus–pituitary–adrenal axis.1 However, risk can accumulate if frequent courses (four or more per year) are given.1

Recurrent courses of oral corticosteroids may also affect bone mineral density, especially in boys.1

Close
Asthma triggers in children: respiratory tract infections

The common cold is a frequent cause of asthma flare-ups in children. Children with asthma have a deficient immune response to rhinovirus infections, irrespective of whether they are atopic.17

Few studies have assessed clinical outcomes in children with acute asthma treated with antibiotics.234

Although upper respiratory tract bacterial infections are associated with increased levels of inflammatory cytokines in the airway,3 which may contribute to wheezing in children, there is insufficient evidence to determine whether antibiotic treatment improves short-term or long-term clinical outcomes.

Macrolide antibiotics may have beneficial effects in asthma through mechanisms other than their antibacterial action,5 but their use in children has not been well investigated.6

The Australian Immunisation Handbook18 recommends annual influenza vaccine for children and adults with asthma that is severe enough to require frequent hospital visits and the use of multiple asthma medicines. It is also recommended for children aged 6 months–5 years (using specific brands registered for use in children).18 Pneumococcal vaccination is recommended for all children under 2 years.18

Asthma, atopic dermatitis (eczema) and allergic rhinitis (hay fever) are not contraindications to any vaccine, unless the child is receiving high-dose oral steroid therapy.

Influenza vaccination reduces the risk of influenza and pneumococcal vaccination reduces the risk of pneumococcal pneumonia. However, the extent to which influenza vaccination and pneumococcal vaccination protect against asthma flare-ups due to respiratory tract infections is uncertain.192021

To be effective, influenza vaccination must be given every year before the influenza season.

There is no significant increase in asthma flare-ups immediately after vaccination with inactivated influenza vaccination.19

For information about immunisation, refer to the current version of The Australian Immunisation Handbook.18

Note: National immunisation guidelines include specific recommendations about influenza and pneumococcal vaccinations for Aboriginal and Torres Strait Islander children.

Close

References

  1. 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
  2. Graham V, Lasserson TJ, Rowe BH. Antibiotics for acute asthma. Cochrane Database Syst Rev. 2001; Issue 2: CD002741. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002741/full
  3. Fonseca-Aten M, Okada PJ, Bowlware KL, et al. Effect of clarithromycin on cytokines and chemokines in children with an acute exacerbation of recurrent wheezing: a double-blind, randomized, placebo-controlled trial. Ann Allergy Asthma Immunol. 2006; 97: 457-63. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17069099
  4. Schwerk N, Brinkmann F, Soudah B, et al. Wheeze in preschool age is associated with pulmonary bacterial infection and resolves after antibiotic therapy. PLoS One. 2011; 6: e27913. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3226624/
  5. Johnston SL. Macrolide antibiotics and asthma treatment. J Allergy Clin Immunol. 2006; 117: 1233-1236. Available from: http://www.jacionline.org/article/S0091-6749(06)00741-X/fulltext
  6. Bush A, Pedersen S, Hedlin G, et al. Pharmacological treatment of severe, therapy-resistant asthma in children: what can we learn from where?. Eur Respir J. 2011; 38: 947-58. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21737557
  7. Walters EH, Walters JA, Gibson PG, Jones P. Inhaled short acting beta2-agonist use in chronic asthma: regular versus as needed treatment. Cochrane Database Syst Rev. 2003; Issue 1: CD001285. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001285/full
  8. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from: http://www.ginasthma.org
  9. British Thoracic Society (BTS) Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. Quick Reference Guide. Revised May 2011. BTS, SIGN, Edinburgh, 2008.
  10. Ram FS, Brocklebank DD, White J, et al. Pressurised metered dose inhalers versus all other hand-held inhaler devices to deliver beta-2 agonist bronchodilators for non-acute asthma. Cochrane Database Syst Rev. 2002; Issue 2: CD002158. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002158/full
  11. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
  12. Nikander K, Turpeinen M, Pelkonen AS, et al. True adherence with the Turbuhaler in young children with asthma. Arch Dis Child. 2011; 96: 168-73. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21097795
  13. Sleath B, Ayala GX, Gillette C, et al. Provider demonstration and assessment of child device technique during pediatric asthma visits. Pediatrics. 2011; 127: 642-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21444594
  14. Vuillermin P, South M, Robertson C. Parent-initiated oral corticosteroid therapy for intermittent wheezing illnesses in children. Cochrane Database Syst Rev. 2006; Issue 3: CD005311. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005311.pub2/full
  15. Vuillermin P, Robertson CF, Carlin JB, et al. Parent initiated prednisolone for acute asthma in children of school age: randomised controlled crossover trial. BMJ. 2010; 340: c843. Available from: http://www.bmj.com/content/340/bmj.c843.long
  16. Beigelman A, King TS, Mauger D, et al. Do oral corticosteroids reduce the severity of acute lower respiratory tract illnesses in preschool children with recurrent wheezing?. J Allergy Clin Immunol. 2013; 131: 1518-1525. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23498594
  17. Baraldo S, Contoli M, Bazzan E, et al. Deficient antiviral immune responses in childhood: distinct roles of atopy and asthma. J Allergy Clin Immunol. 2012; 130: 1307-14. Available from: http://www.jacionline.org/article/S0091-6749(12)01291-2/fulltext
  18. Australian Technical Advisory Group on Immunisation (ATAGI), Department of Health and Ageing. The Australian Immunisation Handbook. 10th Edition. Department of Health and Ageing, Canberra, 2013. Available from: http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook10-home
  19. Cates CJ, Jefferson T, Rowe BH. Vaccines for preventing influenza in people with asthma. Cochrane Database Syst Rev. 2008; Issue 2: CD000364.pub3. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000364.pub3/full
  20. Sheikh A, Alves B, Dhami S. Pneumococcal vaccine for asthma. Cochrane Database Syst Rev. 2002; Issue 1: CD002165. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002165/full
  21. Woolcock Institute of Medical Research, Australian Centre for Asthma Monitoring (ACAM), Australian Institute of Health and Welfare (AIHW). Vaccination uptake among people with chronic respiratory disease.. Australian Institute of Health and Welfare (AIHW), Canberra, 2012. Available from: http://www.aihw.gov.au/publication-detail/?id=60129542385