Asthma Management Handbook

Managing triggers in children


Advise parents/carers to ensure that children are not exposed to tobacco smoke. Explain that smoking outdoors near children still exposes children to smoke.

How this recommendation was developed


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

All health professionals should advise parents and household members about cessation options and support them to quit smoking.

How this recommendation was developed

Adapted from existing guidance

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

  • Zwar et al. 20111
  • Aveyard et al. 20122

Identify allergens to which the child is sensitised and avoid allergic triggers, if possible.

Table. Summary of asthma triggers 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).

More information

Asthma triggers in children: tobacco smoke

There is consistent, high-quality evidence that exposure to environmental tobacco smoke can both cause and worsen wheezing in preschool children.3

Asthma triggers in children: environmental allergens

There is insufficient evidence on which to base recommendations for the reduction of exposure to environmental allergens in the treatment of wheezing in preschool children.3

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.4

Few studies have assessed clinical outcomes in children with acute asthma treated with antibiotics.567

Although upper respiratory tract bacterial infections are associated with increased levels of inflammatory cytokines in the airway,6 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,8 but their use in children has not been well investigated.9

The Australian Immunisation Handbook10 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).10 Pneumococcal vaccination is recommended for all children under 2 years.10

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.111213

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.11

For information about immunisation, refer to the current version of The Australian Immunisation Handbook.10

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

Thunderstorm-triggered asthma

Certain types of thunderstorms in spring or early summer in regions with high grass pollen concentrations in the air can cause life-threatening allergic asthma flare-ups in sensitised individuals, even if they have not had asthma before.14, 15, 16, 17, 18 People at risk of acute asthma flare-ups triggered by a thunderstorm include those with seasonal allergic rhinitis (with or without asthma), those with asthma (or a history of asthma), and those with undiagnosed asthma.15

Epidemics of thunderstorm-triggered asthma can occur when such a storm travels across a region and triggers asthma in many susceptible individuals, causing a high demand on ambulance and health services.16 However, epidemic thunderstorm asthma events are uncommon.

Data from thunderstorm asthma epidemics suggest that the risk of asthma flare-ups being triggered by a thunderstorm is highest in adults who are sensitised to grass pollen and have seasonal allergic rhinitis (with or without known asthma).15 The worst outcomes are seen in people with poorly controlled asthma. Regular treatment with an inhaled corticosteroid asthma preventer was significantly protective in a well-conducted Australian case-control study.18

Prevention and management are based on:19

  • year-round asthma control, including inhaled corticosteroid-containing preventers where indicated
  • preventive inhaled corticosteroid treatment for adults and adolescents with asthma who have known or suspected allergy to grass pollens (e.g. concomitant allergic rhinitis, a history of spring flare-ups in asthma symptoms) but are not already taking regular medication. Treatment should at least 2 weeks (ideally 6 weeks) before exposure to springtime high pollen concentrations and thunderstorms and continue throughout the local grass pollen season. For children, asthma should be managed according to age group.
  • preventive intranasal corticosteroid treatment for adults and adolescents with seasonal allergic rhinitis, because it can be reasonably assumed that they are allergic to ryegrass pollen. Treatment should start at least 2 weeks (ideally 6 weeks) before exposure to springtime high pollen concentrations and thunderstorms and continue throughout the local grass pollen season. For children, allergic rhinitis should be managed according to age group.
  • advice for at-risk patients to avoid being outdoors just before and during thunderstorms in spring and early summer, especially during wind gusts that precede the rain front
  • advice to ensure appropriate access to relievers during grass pollen season.


  1. Zwar N, Richmond R, Borland R, et al. Supporting smoking cessation: a guide for health professionals. Updated 2012. The Royal Australian College of General Practitioners (RACGP), Melbourne, 2011. Available from:
  2. Aveyard P, Begh R, Parsons A, West R. Brief opportunistic smoking cessation interventions: a systematic review and meta-analysis to compare advice to quit and offer of assistance. Addiction. 2012; 107: 1066-1073. Available from:
  3. Brand PL, Baraldi E, Bisgaard H, et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach. Eur Respir J. 2008; 32: 1096-1110. Available from:
  4. 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:
  5. Graham V, Lasserson TJ, Rowe BH. Antibiotics for acute asthma. Cochrane Database Syst Rev. 2001; Issue 2: CD002741. Available from:
  6. 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:
  7. 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:
  8. Johnston SL. Macrolide antibiotics and asthma treatment. J Allergy Clin Immunol. 2006; 117: 1233-1236. Available from:
  9. 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:
  10. 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:
  11. 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:
  12. Sheikh A, Alves B, Dhami S. Pneumococcal vaccine for asthma. Cochrane Database Syst Rev. 2002; Issue 1: CD002165. Available from:
  13. 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:
  14. D'Amato G, Vitale C, D'Amato M, et al. Thunderstorm-related asthma: what happens and why. Clin Exp Allergy. 2016; 46: 390-6.
  15. Davies J, Queensland University of Technology. Literature review on thunderstorm asthma and its implications for public health advice. Final report. Victorian State Government Department of Health and Human Services, Melbourne, 2017.
  16. Victoria State Government Department of Health and Human Services,. The November 2016 Victorian epidemic thunderstorm asthma event: an assessment of the health impacts. The Chief Health Officer’s Report, 27 April 2017. Victorian Government, Melbourne, 2017.
  17. Marks GB, Colquhoun JR, Girgis ST, et al. Thunderstorm outflows preceding epidemics of asthma during spring and summer. Thorax. 2001; 56: 468-71. Available from:
  18. Girgis ST, Marks GB, Downs SH, et al. Thunderstorm-associated asthma in an inland town in south-eastern Australia. Who is at risk?. Eur Respir J. 2000; 16: 3-8. Available from:
  19. National Asthma Council Australia. Thunderstorm asthma. An information paper for health professionals. NACA, Melbourne, 2017.