Asthma in children

Consider asthma if

Dyspnea (shortness of breath) and/or wheeze (whistling sound on breathing out) with physical activity or at rest
Wheeze with other allergy symptoms (eg sneezing, eczema)
Recurrent wheeze with chest infection if over 1 year
Dry frequent cough especially at night, without a cold
Chest tightness
Family history of asthma

Diagnosis

Based on history and physical examination — confirmed by reduced or resolved shortness of breath and/or wheeze after using inhaled bronchodilators

In infants and toddlers wheeze is often due to bronchiolitis or transient early wheeze — not asthma
Cough without wheeze or shortness of breath is rarely asthma. Check for CSLD/bronchiectasis

Managing an asthma attack

Red Flags — Urgent Medical Consult
Apnoea (stops breathing for short periods) — mainly infant Increased work of breathing (any age) Oxygen saturation less than 90% on room air or less than 94% on oxygen and not improving Not able to eat/feed Not interested in what is happening, lethargic (drowsy) Reduced air entry or silent chest Cyanosis (blue lips or tongue)

Do

Use Table 3.13 to assess severity (how bad the attack is) — may be difficult to identify, unwell child may be quiet

Table 3.13 Severity of asthma

Sign	Mild or moderate	Severe	Life threatening
Behaviour	Normal	Normal, anxious	Agitated or distressed, may look exhausted
Talking	Easily	Phrases only	Single words
Chest recession	No	Mild	Moderate or marked
Wheeze	Variable	Moderate	May be soft due to small amount of air movement
O₂ sats on room air	94% or more	90–93%	Less than 90%

Life threatening asthma

Do first

Sit person up — carry or use wheelchair to move them
Start oxygen if O₂ sats less than 92% and titrate to target oxygen saturation of 93–95%

Do not over-oxygenate to avoid risk of hypercapnia (CO₂ retention)

Give salbutamol nebulised as needed — 5mg AND ipratropium nebulised as needed — can mix with salbutamol

Under 6 years — ipratropium 250microgram
6 years or over — ipratropium 500microgram

Nebulisers have high risk of transmitting infection. Wear full PPE
Urgent medical consult
Calculate age-appropriate REWS — AVPU, respiratory distress, RR, O₂ sats, pulse, central capillary refill time, Temp

Do

Give oxygen to target O₂ sats at least 95%
Give hydrocortisone IM/IV — child 4mg/kg/dose up to 100mg — doses — can repeat after 6 hours
If poor response consider — magnesium sulfate IV — child over 2 years 0.2mmol/kg up to 10mmol, slow infusion over 20 minutes AND adrenaline (epinephrine) IM — child 0.01mg/kg

If getting better — consider reducing salbutamol to every 30 minutes

Under 6 years — salbutamol 2.5mg
6 years or over — salbutamol 5mg

Severe asthma

Do first

Urgent medical consult

Give medicine by puffer with spacer, shake puffer before each spray. If under 3 years or unable to use mouth piece — use mask

Each puff is sprayed into spacer and inhaled for a few breaths before the next puff

Give salbutamol puffer with spacer — 100microgram/dose

Under 6 years — 6 puffs
6 years or over — 12 puffs

Give ipratropium puffer with spacer (or mask) — 21microgram/dose

Under 6 years — 4 puffs
6 years or over — 8 puffs

Repeat salbutamol with ipratropium every 20 minutes OR If patient cannot breathe through spacer or mask use intermittent nebulisation driven by oxygen

Nebulisers have high risk of transmitting infection and should only be used if absolutely necessary. Wear full PPE
Give salbutamol with nebuliser

Under 6 years — 2.5mg
6 years or over — 5mg

ADD ipratropium to nebuliser

Under 6 years — 250microgram
6 years or over — 500microgram

Repeat salbutamol with ipratropium every 20 minutes

Calculate age-appropriate REWS — AVPU, respiratory distress, RR, O₂ sats, pulse, central capillary refill time, Temp
Weight, BGL

Do

Give oxygen to target O₂ sats at least 95%
Give hydrocortisone IM/IV — child 4mg/kg/dose up to 100mg — doses — can repeat after 6 hours
If not getting better — treat as life threatening asthma

Moderate and mild asthma

Ask

About wheeze and cough and what makes them worse
How many days have they been sick
How many days missed school
Do they have asthma action plan, have they followed it
What medicines have they already used to manage attack
Previous hospitalisations for asthma, especially intensive care admissions
Exposure to tobacco smoke, e-cigarettes, campfire smoke

Check

Calculate age-appropriate REWS — AVPU, respiratory distress, RR, O₂ sats, pulse, central capillary refill time, Temp
Weight, BGL

Head-to-toe exam

Look at how they are breathing
Listen to front and back of chest for wheeze, air entry

Do

Medical consult
Give oxygen to target O₂ sats at least 95%
Give salbutamol puffer with spacer — 100microgram/dose. If under 3 years or unable to use mouth piece — use mask

Each puff is sprayed into spacer and inhaled for a few breaths before the next puff
Under 6 years — 4 puffs
6 years or over — 8 puffs
Repeat dose after 20 minutes

Give prednisolone oral — child 1mg/kg/dose up to 50mg — doses — single dose
Check how hard child is breathing every 15 minutes
If not better — treat as severe asthma
If better — keep in clinic for 1 hour. If condition stable — send home

Advise salbutamol puffer with spacer — 100microgram/dose — 4 puffs if under 6 years, 8 puffs if 6 years or over — every 3–4 hours
Give prednisolone oral — child 1mg/kg/dose up to 50mg — doses — once a day for 2 more days
Make management plan. Update asthma action plan, give copy to child/family
Review every day
Arrange asthma education. Use cultural specific resources if available
Medical follow-up at next visit

Managing ongoing asthma

Asthma management in children is based on

Education — make sure child and family understand and can manage asthma including how to use devices and make a bush spacer
Triggers identified and avoided, including fire, e-cigarettes and tobacco smoke
Assessment of asthma type, symptoms, severity and control
Achieving and maintaining best lung function
Preventing exacerbations
Asthma action plan developed — reviewed regularly

Do

Manage by asthma type — Table 3.14
Adjust asthma medicines (up or down) according to severity and level of control — Table 3.15
Aim for good control with least amount of medicine, especially with inhaled corticosteroids

Table 3.14 Management by asthma type

Asthma type	Management
Infrequent, intermittent (occasional) asthma Short mild attacks more than 6 weeks apart Usually triggered by virus No symptoms between attacks	Use salbutamol for symptoms Child under 6 years may also need low dose inhaled corticosteroid treatment for wheeze
Frequent intermittent (mild) asthma Mild/moderate attacks less than 6 weeks apart No symptoms between attacks	Use salbutamol for symptoms and before physical activity if needed Consider preventer Low dose inhaled corticosteroid OR montelukast (2 years and over)
Persistent asthma Frequent attacks — mild, moderate or severe Symptoms between attacks Hospital admissions	Use salbutamol for symptoms and before physical activity Use preventer Start with low dose inhaled corticosteroid OR montelukast (2 years and over) If symptoms not controlled Low dose inhaled corticosteroid AND montelukast (2 years and over) OR medium dose inhaled corticosteroid If symptoms still not controlled 6 years or over — consider combined therapy (inhaled corticosteroids + long-acting beta₂ agonist) Under 6 years — refer to specialist

Table 3.15 Levels of asthma symptom control

Level of control	Features — over 4 week period
Good control	All of Daytime symptoms — 0–2 days/week, last only a few minutes, quickly relieved by bronchodilator No limitation of activities No symptoms during night or when wakes up Need to use reliever — 0–2 days per week*
Partial control	Any of Daytime symptoms — 3–7 days/week, last only a few minutes, quickly relieved by bronchodilator Any limitation of activities Any symptoms during night or when wakes up Need to use reliever — 3–7 days/week*
Poor control	Either of Daytime symptoms — 3–7 days/week, last from minutes to hours or recurring, partially or fully relieved by bronchodilator 3–4 features of partial control in 1 week

All of

Daytime symptoms — 0–2 days/week, last only a few minutes, quickly relieved by bronchodilator
No limitation of activities
No symptoms during night or when wakes up
Need to use reliever — 0–2 days per week*

Any of

Daytime symptoms — 3–7 days/week, last only a few minutes, quickly relieved by bronchodilator
Any limitation of activities
Any symptoms during night or when wakes up
Need to use reliever — 3–7 days/week*

Either of

Daytime symptoms — 3–7 days/week, last from minutes to hours or recurring, partially or fully relieved by bronchodilator
3–4 features of partial control in 1 week

* Not including reliever used for prevention before physical activity

Regular reviews

How often will depend on type of asthma — check asthma action plan
Child on long-term corticosteroids should see a paediatrician at least once a year
If child needs high dose corticosteroids and/or symptoms persist — consider other diagnosis (eg bronchiectasis)

Ask

How often and when do they get symptoms — cough, wheeze, waking at night or early morning
How often do they use reliever during day and night
Does asthma stop them doing things (eg running, playing, going to school)
Any problems using the medicines — for example with devices, eg spacers

Check

Every 6 months check that puffer and spacer or other devices used correctly
If over 6 years or over — spirometry (lung function)
Immunisation status

Do

Review and update asthma action plan with child and family
Give advice on avoiding triggers (eg no smoking in house, avoid camp fire smoke)

Asthma medicines

Table 3.16 Asthma medicines

Used as	Medicine type	Examples
Reliever — relief of symptoms	Bronchodilator	Salbutamol Terbutaline Ipratropium
Preventer — prevent symptoms happening	Inhaled corticosteroid	Beclometasone Budesonide Ciclesonide Fluticasone propionate
Preventer — prevent symptoms happening	Oral	Montelukast
Combined therapy — preventer and long-acting reliever	Inhaled corticosteroid + long-acting beta₂ agonist	Budesonide + formoterol (eformoterol) Fluticasone propionate + salmeterol

Table 3.17 Total daily doses of inhaled corticosteroids for children

Inhaled corticosteroid	Low dose (microgram)	Medium dose (microgram)	High dose (microgram)
Beclometasone (with HFA – CFC free)	100	100–200	200–400
Budesonide	100–200	300–400	400–800
Ciclesonide	80	160	160–320
Fluticasone propionate	100	100–200	200–500

Inhaled therapy devices

Puffers (metered dose inhalers/MDIs) work best with spacer

Have child show you their puffer and spacer techniques and give education on correct use and cleaning — see Spacer devices for respiratory medicines
Check they know how to make a bush spacer

Relievers (bronchodilators) work as well with puffer and spacer as with nebuliser — except in very severe asthma

Salbutamol 100microgram/dose puffer 8–12 puffs = salbutamol 5mg nebulised
Table 3.18 for spacer types and sizes

Other devices available for older children (8 years and over) — find device child prefers or works best for them
Dry powder devices (DPIs) (eg turbuhaler, Accuhaler)

Can get blocked in very humid climates
Need to be able to take a big enough breath to make work
Not usually recommended for young children

Table 3.18 Puffers and spacers

Age (years)	Type and size
Under 3	Puffer with small volume spacer and mask
3–6	Puffer with small volume spacer
Over 6	Puffer with small or large volume spacer

Asthma action plan

Every child with asthma needs written or picture based asthma action plan developed in consultation with a doctor. Keep copy at home, at school, in file notes. Make sure child and/or family understand how to use it. Illustrated Indigenous asthma action plans available online

Includes

What to do when

Child well
Asthma a bit worse, they get cold or chest infection
Asthma severe

How often they need regular reviews, medical reviews, paediatrician reviews
When to collect medicines, have immunisations

ASTHMA ACTION PLAN
Name ________________________________________ Date ____________________
When my asthma is well controlled
Reliever (for relief of wheeze or cough)
____________________________________________________ Use _____ times a day
Preventer Yes/No
____________________________________________________ Use _____ times a day
____________________________________________________ Use _____ times a day
Symptom controller Yes/No
____________________________________________________ Use _____ times a day
Before exercise/physical activity I take _________________________________________

When my asthma is getting worse or I have a cold
If the cough or wheeze increase or at the first sign of a cold
Reliever
____________________________________________________ Use _____ times a day
Preventer Yes/No
____________________________________________________ Use _____ times a day
____________________________________________________ Use _____ times a day
Symptom controller Yes/No ____________________________________________________ Use _____ times a day
When the asthma gets better go back to the 'well controlled' plan.

When my asthma is severe or getting worse quickly
Extra things to do
_________________________________________________________________________ _________________________________________________________________________
Emergency medicines _________________________________________________________________________ _________________________________________________________________________
If still getting worse, go to the clinic or hospital.
When the asthma gets better go back to the 'well controlled' plan.

Check up at the clinic every ____ months even if well.
Check up with doctor ___________________________________________________
Check up with paediatrician / specialist __________________________________
Medicines due ____________________ Immunisations due ___________________

Supporting resources

The CRE in Lung Health resources
Lung health for kids app
How to use a puffers and spacer for kids video
Asthma handbook — managing asthma in children