Clinical FeaturesRespiratory

Management of Asthma in Children

Written by Ruth Morrow, Respiratory Nurse Specialist, Asthma Society of Ireland

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation which is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness and cough that vary over time and in intensity, together with variable expiratory airflow limitation (GINA, 2021)

Asthma is one of the most common chronic diseases worldwide affecting an estimated 300 million. Prevalence is increasing in many countries, especially in children. Asthma is a major cause of school and work absence (Manning et al., 2005). The Asthma Society of Ireland estimate that that 1 in 5 children experience asthma at some stage in their life. Poorly controlled asthma is expensive in terms of hospitalisations, visits to out of hour services, days missed from school and the negative impact on quality of life for children and their families. The Asthma Insights and Reality in Europe study revealed that a child with asthma will lose 10 days from school per year (Manning et al., 2005, Manning et al., 2007)


In children, asthma can be difficult to diagnose due to various differential diagnoses and the inability to perform peak flow readings in children under 5 years of age. A comprehensive and accurate history taking is essential and should include family history, medical and surgical history of the child, birth history, medications and trigger factors. Children born prematurely are at higher risk of developing it. Symptom history includes duration, type, onset, and pattern of symptoms. Symptom history can be difficult to obtain with some parents being vague about symptoms and the use of symptom diary is useful in these situations.

The Global Initiative for the diagnosis and Management of Asthma (GINA) provide professionals with a guide for symptom patterns in children which is useful in determining the probability of an asthma diagnosis (Figure 1). In children over 5, it is useful to carry out a peak flow diary for 2 weeks with the child recording their peak flow twice daily. Reversibility testing to Salbutamol can also be carried out for these children with an increase in PEFR of 12% indicating a positive diagnosis for asthma. Spirometry with bronchodilator reversibility may also be performed in children over 5.

There is an increased probability that symptoms are due to asthma if:

  • There is more than one type of symptom (wheeze, shortness of breath, cough, chest tightness)
  • Symptoms often worse at night or in the early morning
  • Symptoms vary over time and in intensity
  • Symptoms are triggered by viral infections, exercise, allergen exposure, changes in weather, laughter, irritants such as car exhaust fumes, smoke, or strong smells

There is a decreased probability that symptoms are due to asthma if:

  • The cough is isolated with no other respiratory symptoms
  • There is chronic production of sputum
  • There is shortness of breath associated with dizziness, light-headedness or peripheral tingling
  • Symptoms are exercise induced dyspnoea with noisy inspiration (stridor)

Physical assessment includes height and weight measurement. Chest examination to include chest expansion, percussion and auscultation. Chest x-ray is not indicated for the diagnosis of asthma unless the child fails to respond to inhaled treatment. Allergy testing may be useful in helping to identify possible trigger factors. Forced Exhaled Nitrous Oxide (FEN0) testing can be helpful to confirm the diagnosis and to assess eosinophilic inflammation.

Assessment and identification of trigger factors can be challenging and very often, parents may not be aware of the potential trigger factors. Asking the parent to observe for potential trigger factors and use a symptom tracker over a period of time can be useful. Trigger factors can be inhaled (house dust mite, pollen, strong odours, smoke, animal dander), swallowed (foods, food additives and preservatives, medications such as Ibuprofen and betablockers) and non-allergic such as exercise, laughing or crying.

The differential diagnosis for asthma includes inhaled foreign body, cystic fibrosis, primary ciliary dyskinesia, bronchopulmonary dysplasia and immune deficiency. Failure to respond to treatment warrants further investigation to out rule any of these conditions.

Management of Stable Asthma

The goals of asthma management are:

  1. Symptom control: to achieve good control of symptoms and maintain normal activity levels
  2. Risk reduction: to minimize future risk of exacerbations, fixed airflow limitation and medication side-effects

Assessment of asthma control involves assessing symptoms over the previous 4 weeks and assessing risk factors for poor outcomes. Treatment issues should also be addressed at every visit and should include:

  • Checking inhaler technique and adherence
  • Asking about side-effects
  • Reviewing the child’s written asthma action plan?
  • Exploring the parent’s attitudes and goals for their asthma?

The Asthma Control Test (ACT) for children is a useful tool to assess the child’s level of control and the impact asthma may be having on their day-to-day life (available on https://www.

GINA (2021) provides a step-wise approach for the pharmacological management of asthma. In a recent change to the guidelines, an inhaled corticosteroid should be used at the same time when Salbutamol is used. Children who are using Salbutamol more than twice a week should be commenced on inhaled corticosteroids. If the child is not controlled on the appropriate step, inhaler technique and adherence to medication should be reviewed before moving up to the next step. Once optimal control has been achieved for at least 3 months, then medication can be titrated down.

MDI with spacer is the first choice for the delivery of medication in stable asthma for children under 5 and up to the age of 7/8. After this, a dry powder device or breath actuated device may be an option for the delivery of treatment. Nebulizers should be reserved for the management of severe acute exacerbations of asthma. Side effects of inhaled corticosteroid medication include dysphonia and oral candidiasis and parents should be educated in the avoidance of these side effects ie rinsing the mouth out and brushing the teeth. Where face masks are used, it is vital to ensure that mask is the correct size and fits correctly to form a seal around the mouth and nose so as to avoid deposition of the drug into the eyes. The face should be washed following administration of inhaled corticosteroids.

Risk factors for poor outcomes

Children who experience uncontrolled asthma symptoms, had one or more exacerbation in the previous year, the start of the child’s usual ‘flare-up’ season (especially if autumn), has major psychological or socio-economic problems for child or family, poor adherence with controller medication, or children with incorrect inhaler technique are at risk of an exacerbation in the coming months.

Asthma and COVID19 in children with asthma

A study by Shi et al (2021) explored data from primary care, community prescribing, hospital admissions, and deaths. It provides a detailed insight into the risk of severe SARS-CoV-2 in children aged 5–17 years with asthma in Scotland. The findings from Shi and colleagues’ study suggest that compared with children without asthma, the risk of admission to hospital with COVID-19 is increased in children with a diagnosis of asthma particularly when they have previously been admitted to hospital with asthma or have required two or more courses of oral corticosteroids in the 24 months before the study start date in March 2020.

Assessment and Management of Acute asthma

Accurate and timely assessment of acute asthma exacerbations should be carried out to ensure a successful outcome. Table 1 differentiates between a mild and severe acute exacerbation.

The management of acute asthma includes:

  1. Oxygen therapy – 24% delivered by face mask (usually 1L/min) to maintain oxygen saturation 94-98%
  2. Inhaled short-acting bronchodilator – 2–6 puffs of Salbutamol by spacer, or 2.5mg by nebulizer, every 20 min for first hour, then reassess severity. If symptoms persist or recur, give an additional 2-3 puffs per hour. Admit to hospital if >10 puffs required in 3-4 hours.
  3. Oral corticosteroids – Give initial dose of oral prednisolone (1- 2mg/kg up to maximum of 20mg for children <2 years; 30 mg for 2-5 years).
  4. Additional treatments can include – For moderate/severe exacerbations, give 2 puffs of ipratropium bromide 80mcg (or 250mcg by nebulizer) every 20 minutes for one hour only.

All children who experience an acute exacerbation of asthma should be reviewed 6 hours after their event if they are not referred to secondary care. Criteria for immediate transfer to secondary care include:

I. Features of severe exacerbation at initial or subsequent assessment

  • Child is unable to speak or drink
  • Cyanosis
  • Subcostal retraction
  • Oxygen saturation <92% when breathing room air
  • Silent chest on auscultation

II. Lack of response to initial bronchodilator treatment

  • Lack of response to 6 puffs of inhaled SABA (2 separate puffs, repeated 3 times) over 1-2 hours
  • Persisting tachypnoea despite 3 administrations of inhaled SABA, even if the child shows other clinical signs of improvement

III. Unable to be managed at home

  • Social environment that impairs delivery of acute treatment
  • Parent/carer unable to manage child at home

This article has explored asthma in children which can be difficult and challenging to diagnose and treat. It is the most common chronic condition affecting over 10% of children. The burden of childhood asthma is significant in terms of healthcare costs and the impact on the child’s and family’s quality of life. With good control, children can expect to live a normal and fulfilled childhood.

Asthma Awareness Week runs from 1-7 May 2022. The Asthma Society of Ireland are running a webinar for health care professionals and parents/ guardians on Thursday 5th May 2022 with Dr Tariq Consultant Paediatrician with Asthma & Allergy and Lisa Egan Respiratory Paediatric ANP from the Midlands Hospital, Portlaoise.

References available on request

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