Asthma Management Handbook

Assessing symptoms and control in children 6 years and over

Recommendations

For children with a new asthma diagnosis or those not taking regular preventer treatment, assess frequency and severity of symptoms and flare-ups.

Note: This assessment should be based on overall pattern of symptoms including frequency of flare-ups and symptoms between flare-ups, not on symptoms seen during a flare-up.

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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How this recommendation was developed

Consensus

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

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Assess level of recent asthma symptom control.

Notes: If reliable equipment and appropriately trained staff are available, spirometry can be performed in primary care. If not, refer to an appropriate provider such as an accredited respiratory function laboratory.

Most children aged 6 and older can perform spirometry reliably.

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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How this recommendation was developed

Consensus recommendation following inconclusive literature search

Based on clinical experience and expert opinion after literature review yielded insufficient evidence for an evidence-based recommendation

Key evidence considered:

  • Abramson et al. 20151
  • Deschildre et al. 20122
  • Haahtela et al. 20063

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Assess risk factors for flare-ups.

Table. Risk factors for life-threatening asthma flare-ups in children

Asthma-related factors

Poor asthma control

Admission to hospital in preceding 12 months

History of intubation for acute asthma

Over-use of short-acting beta2 agonist reliever

Abnormal spirometry findings

Reversible expiratory airflow limitation on spirometry despite treatment

Poor adherence to preventer

Incorrect inhaler technique for preventer

Poor adherence to asthma action plan

Exposure to clinically relevant allergens

Exposure to tobacco smoke

Other clinical factors

Allergies to foods, insects, medicines

Obesity

Family-related factors

Frequent failure to attend consultations/lack of follow-up after an acute flare-up

Significant parental psychological or socioeconomic problems

Parent/carer unequipped to manage asthma emergency

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How this recommendation was developed

Consensus

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

Last reviewed version 2.0

Perform spirometry in children able to do this test reliably.

If spirometry is normal, it should be repeated at planned asthma reviews at least yearly.

If spirometry is abnormal, it should be checked again 4–6 weeks after starting treatment or changing the treatment regimen.

How this recommendation was developed

Consensus recommendation following inconclusive literature search

Based on clinical experience and expert opinion after literature review yielded insufficient evidence for an evidence-based recommendation

Key evidence considered:

  • Abramson et al. 20151
  • Deschildre et al. 20122
  • Haahtela et al. 20063

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If the diagnosis of asthma was made elsewhere, confirm the diagnosis, if possible.

How this recommendation was developed

Consensus

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

Last reviewed version 2.0

More information

Classification of symptom patterns in children

The pattern and severity of symptoms in a child with asthma or preschool wheeze is a guide to initial treatment.

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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Table. Definitions of asthma patterns in children aged 6 years and over not taking regular preventer

Category

Pattern and intensity of symptoms (when not taking regular treatment)

Infrequent intermittent asthma †

Symptom-free for at least 6 weeks at a time (flare-ups up to once every 6 weeks on average but no symptoms between flare-ups)

Frequent intermittent asthma

Flare-ups more than once every 6 weeks on average but no symptoms between flare-ups

Persistent asthma

Mild

FEV1 ≥80% predicted and at least one of:

  • Daytime symptoms more than once per week but not every day
  • Night-time symptoms more than twice per month but not every week

Moderate

Any of:

  • FEV1 <80% predicted
  • Daytime symptoms daily
  • Night-time symptoms more than once per week
  • Symptoms sometimes restrict activity or sleep

Severe

Any of:

  • FEV1 ≤60% predicted
  • Daytime symptoms‡ continual
  • Night-time symptoms frequent
  • Flare-ups frequent
  • Symptoms frequently restrict activity or sleep

† It may not be appropriate to make the diagnosis of asthma in children aged 6 or older who wheeze only during upper respiratory tract infections. These children can be considered to have episodic (viral) wheeze.

‡ 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 and health professionals to prevent a serious outcome such as hospitalisation or death from asthma).

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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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For children already taking regular preventer treatment, adjustments to the treatment regimen are based on finding the lowest dose of medicines that will maintain good control of symptoms.

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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 
  • the degree to which asthma symptoms affect daily activities such as interference with physical activity or missed school days)
  • the frequency of flare-ups
  • spirometry in children who are able to perform the test reliably.

Standardised questionnaires

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

Lung function tests

Frequent spirometry to guide asthma treatment in children has not been shown to achieve superior outcomes to symptom-based treatment.8 Current evidence does not support use of home spirometers to guide asthma treatment in children.2 However, low FEV1 predicts clinically significant flare-ups, so spirometry should be performed at asthma reviews for children who are old enough to do the test.
The quality and utility of spirometry depends on the skill, clinical expertise and experience of the person doing and interpreting spirometry.

The results of one study in children aged 6–16 years with moderate atopic asthma suggest that asthma treatment guided by airway hyperresponsiveness (measured by bronchial provocation testing) may have a benefit over symptom-guided treatment in improving lung, but this effect was lost after 3–7 years of usual care.910 Repeated bronchial provocation testing is not feasible in clinical practice.

Measures of airway inflammation

Measures of airway inflammation (e.g. sputum eosinophil count, exhaled nitric oxide measurement) are not recommended in primary care to guide treatment decisions, but are increasingly used in specialist clinics.

Asthma treatment guided by sputum eosinophil count has been shown to reduce the frequency of flare-ups in adults with asthma, but there is insufficient evidence to ascertain its value for children.11

Exhaled nitric oxide measurement may be useful in guiding asthma management in some children. In children not taking inhaled corticosteroid, a high nitric oxide level probably predicts a good short-term response to inhaled corticosteroid treatment,12 but it does not distinguish between asthma and eosinophilic bronchitis and is often high in children with atopy. There is insufficient evidence to ascertain whether a low exhaled nitric oxide level predicts successful withdrawal from inhaled corticosteroids without asthma relapse,12 or safety of treating asthma without inhaled corticosteroids.

A Cochrane review13 found that exhaled nitric oxide-guided management was significantly better than other approaches to adjusting medicines for reducing the number of children with flare-ups and the number of children who needed oral corticosteroids, but did not reduce the frequency of flare-ups or the rate of flare-ups requiring hospitalisation, improve lung function or symptoms scores, or reduce inhaled corticosteroid doses. The authors concluded that it could not be recommended for all children but may be beneficial for a subset not yet defined.13

Towards personalised asthma care

Emerging understanding of asthma phenotypes and of genetic factors that predict therapeutic response to preventer options is leading to the possibility of personalised, genomics-based treatment for asthma in children.14 In the near future, individual tailored therapy is may replace the standardised step model based on population data.

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Role of spirometry in the diagnosis of asthma in children

Generally, spirometry cannot be performed to acceptable standards in children younger than 4–5 years.15

Some older children cannot perform spirometry either. However, children who are unable to perform spirometry satisfactorily on their first visit are often able to perform the test correctly at the next visit.15

Normal spirometry in a child, especially when asymptomatic, does not exclude the diagnosis of asthma. FEV1 is often normal in children with persistent asthma.

Reduced FEV1 alone does not indicate that a child has asthma, because it may be seen with other lung diseases (or be due to poor spirometric technique). However, reduced ratio of FEV1 to FVC for age indicates expiratory airflow limitation.

A significant increase in FEV1 (>12% from baseline) after administering a bronchodilator (e.g. 2–4 puffs of salbutamol 100 microg/actuation) indicates that airflow limitation is reversible and supports the diagnosis of asthma. However, an absent response to bronchodilators does not exclude asthma.

In children with asthma, bronchodilator reversibility is also predictive of a good lung function response to inhaled corticosteroids.16

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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.17 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.17

  • There are significant concerns about use of cough medicines in children.

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References

  1. Abramson, M. J., Schattner, R. L., Holton, C., et al. Spirometry and regular follow-up do not improve quality of life in children or adolescents with asthma: Cluster randomized controlled trials. Pediatr Pulmonol. 2015; 50: 947-54. Available from: https://www.ncbi.nlm.nih.gov/pubmed/25200397
  2. Deschildre A, Beghin L, Salleron J, et al. Home telemonitoring (forced expiratory volume in 1 s) in children with severe asthma does not reduce exacerbations. Eur Respir J. 2012; 39: 290-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/21852334
  3. Haahtela, T., Tuomisto, L. E., Pietinalho, A., et al. A 10 year asthma programme in Finland: major change for the better. Thorax. 2006; 61: 663-70. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmid/16877690/
  4. Murphy KR, Zeiger RS, Kosinski M, et al. Test for respiratory and asthma control in kids (TRACK): a caregiver-completed questionnaire for preschool-aged children. J Allergy Clin Immunol. 2009; 123: 833-9. Available from: http://www.jacionline.org/article/S0091-6749(09)00212-7/fulltext
  5. Zeiger RS, Mellon M, Chipps B, et al. Test for Respiratory and Asthma Control in Kids (TRACK): clinically meaningful changes in score. J Allergy Clin Immunol. 2011; 128: 983-8. Available from: http://www.jacionline.org/article/S0091-6749(11)01287-5/fulltext
  6. Liu AH, Zeiger R, Sorkness C, et al. Development and cross-sectional validation of the Childhood Asthma Control Test. J Allergy Clin Immunol. 2007; 119: 817-25. Available from: http://www.ncbi.nlm.nih.gov/pubmed/17353040
  7. Liu AH, Zeiger RS, Sorkness CA, et al. The Childhood Asthma Control Test: retrospective determination and clinical validation of a cut point to identify children with very poorly controlled asthma. J Allergy Clin Immunol. 2010; 126: 267-73, 273.e1. Available from: http://www.ncbi.nlm.nih.gov/pubmed/20624640
  8. Abramson MJ, Schattner RL, Holton C et al. Spirometry and regular follow-up do not improve quality of life in children or adolescents with asthma: Cluster randomized controlled trials. Pediatr Pulmonol 2015; 50: 947-54. (Available from: https://www.ncbi.nlm.nih.gov/pubmed/25200397
  9. Nuijsink M, Hop WC, Sterk PJ et al. Long-term asthma treatment guided by airway hyperresponsiveness in children: a randomised controlled trial. Eur Respir J 2007; 30: 457-66. (Available from: https://www.ncbi.nlm.nih.gov/pubmed/17537770
  10. Nuijsink M, Vaessen-Verberne AA, Hop WC et al. Long-term follow-up after two years of asthma treatment guided by airway responsiveness in children. Respir Med 2013; 107: 981-6. Available from: https://www.ncbi.nlm.nih.gov/pubmed/23672993
  11. Petsky HL, Li A, Chang AB. Tailored interventions based on sputum eosinophils versus clinical symptoms for asthma in children and adults. Cochrane Database Syst Rev 2017; 8: Cd005603. Available from: https://www.ncbi.nlm.nih.gov/pubmed/28837221
  12. Lehtimaki L, Csonka P, Makinen E et al. Predictive value of exhaled nitric oxide in the management of asthma: a systematic review. Eur Respir J 2016; 48: 706-14. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27492830
  13. Petsky HL, Kew KM, Chang AB. Exhaled nitric oxide levels to guide treatment for children with asthma. Cochrane Database Syst. Rev 2016; Issue 11: CD011439. Available from: https://www.ncbi.nlm.nih.gov/pubmed/27825189/
  14. Turner S, Francis B, Vijverberg S et al. Childhood asthma exacerbations and the Arg16 beta2-receptor polymorphism: A meta-analysis stratified by treatment. J Allergy Clin Immunol 2016; 138: 107-13.e5. Available from: https://www.ncbi.nlm.nih.gov/pubmed/26774659
  15. Johns DP, Pierce R. Pocket guide to spirometry. 3rd edn. McGraw Hill, North Ryde, 2011.
  16. Szefler, SJ, Phillips, BR, Martinez, FD, et al. Characterization of within-subject responses to fluticasone and montelukast in childhood asthma. J Allergy Clin Immunol. 2005; 115: 233-242. Available from: https://www.ncbi.nlm.nih.gov/pubmed/15696076
  17. Gibson PG, Chang AB, Glasgow NJ, et al. CICADA: cough in children and adults: diagnosis and assessment. Australian cough guidelines summary statement. Med J Aust. 2010; 192: 265-271. Available from: https://www.mja.com.au/journal/2010/192/5/cicada-cough-children-and-adults-diagnosis-and-assessment-australian-cough