Asthma – Primary School-Aged Children (6-11 Years)

Managing Asthma in Children

Overview

Children aged 0–12 months:

• Do not treat wheezing infants for asthma; it is usually due to acute viral bronchiolitis or small/floppy airways.
• Consult a paediatric respiratory physician or paediatrician before administering short-acting beta2 agonists, systemic corticosteroids, or inhaled corticosteroids.
• Refer infants with significant wheezing requiring hospitalization or frequent wheezing (e.g., more than once every 6 weeks) to a specialist.

Children aged 1–5 years:

• Many infants and preschoolers wheeze with viral respiratory infections without having asthma.
• Use as-needed salbutamol for symptom relief during wheezing episodes if salbutamol-responsive.
• Some may need regular preventer treatment for recurrent symptoms between viral infections.

Children aged 6 years and over:

• Asthma diagnosis can be more certain with spirometry showing reversible expiratory airflow limitation.
• All school-aged children with asthma need a reliever for symptoms.
• Regular preventer treatment for frequent intermittent asthma or persistent symptoms and those with severe flare-ups, regardless of flare-up frequency.

General Principles of Asthma Treatment in Children

• Aim for good control of asthma symptoms.
• Identify and manage triggers (e.g., allergens).
• Manage comorbid conditions affecting asthma (e.g., allergic rhinitis).
• Educate parents and children (if old enough) on when and how to take reliever medicine.
• Regularly monitor and adjust treatment to maintain good control and prevent flare-ups, minimizing inhaled corticosteroid doses if needed.

Provide Parents/Carers and Children with:

• A written asthma action plan for worsening symptoms.
• Information on reducing exposure to triggers (e.g., avoiding tobacco smoke, reducing allergens when appropriate).
• Training on correct medicine use, including inhaler technique.
• Support to maximize adherence.
• Advice on avoiding tobacco smoke, healthy eating, physical activity, maintaining a healthy weight, and immunization.

Asthma medications and delivery devices include:

• Inhaled corticosteroid (ICS)
• Short-acting β-agonist (SABA)
• Long-acting β-agonist (LABA)
• Metered dose inhaler (MDI)
• Dry powder inhaler (DPI)

Frequent use of SABA alone (>3 MDI canisters per year) and infrequent use of preventer/anti-inflammatory:

• Associated with more severe asthma exacerbations
• Associated with increased risk of death

ICS-formoterol MART (ICS-formoterol maintenance and reliever therapy or “SMART”):

• Worth considering in children nearing 12 years with poor adherence to preventers
• Useful for children with high SABA use
• Refer to guidelines for asthma management in adolescents (12 years and over)

MDI and carbon footprint:

• MDIs have a large carbon footprint
• Reducing impact includes:
  • Achieving good asthma control to reduce need for SABA
  • Switching to DPI when possible (many children can use DPI from about age 6)
  • Prescribing 1 puff of a stronger dose preventer instead of 2 puffs of a weaker dose, especially if dose is stable
  • Using once-daily medication (e.g., ciclesonide)
  • Implementing dose tracking

Assessment

History

Diagnosis is based on symptoms (wheeze, breathlessness, cough) and treatment response (ie recurrent clusters of symptoms that respond to SABA or chronic symptoms that respond to ICS) in the absence of red flags

Red flags for alternative diagnoses: 

• productive cough
• isolated cough
• paraesthesia
• chest pain
• clubbing

Risk of exacerbation

• History of intubation or intensive care unit (ICU) admission for asthma
• 2 or more presentations to hospital that require treatment for asthma
• Using SABA more than twice weekly or >3 MDI canisters per year
• Infrequent use/poor adherence of preventer/anti-inflammatory
• Incorrect inhaler technique
• Exposure to smoke/vaping
• Other comorbidities eg obesity, sleep apnoea, chronic rhinosinusitis, confirmed food allergy

Assessment of asthma control
Good asthma control is defined as:

• Daytime symptoms less than two times per week
• Need for reliever/SABA less than two times per week
• No limitation of activities
• Nighttime waking due to asthma less than two times per month
• No need for systemic corticosteroid, ED presentation or admission

Consider contributing factors:

• Allergic rhinitis
• Obesity
• Obstructive sleep apnoea
• Gastro-oesophageal reflux
• Dysfunctional breathing (including vocal cord dysfunction)
• Depression/anxiety (may present as chest tightness without wheeze)
• Smoking and vaping (passive or active)
• Damp, mouldy, cold or crowded housing
• Aeroallergens, thunderstorm asthma
• Barriers to accessing healthcare

Examination

• Review inhaler technique
• Look for signs of comorbidity, including allergic rhinitis and eczema
• Measure height and weight
• Respiratory examination

Management

Investigations

No investigations are required unless considering an alternative diagnosis

• Spirometry may have a role in children in whom the diagnosis or severity is uncertain
• Allergy testing (RAST/skin prick testing) should not be performed if there is no history of an immediate reaction to the potential allergen
  • A clear relationship between an allergen and asthma symptoms also does not require testing, rather this should be treated as an allergic trigger and avoided where possible

Treatment

Education

• Assess knowledge and understanding and address gaps on
  • symptom recognition and management
  • when to seek medical attention
  • emergency management
  • role of reliever and preventer treatment
  • inhaler technique
• Recommend annual influenza vaccine
• Check adherence at every visit and address barriers
• Asthma Action Plan: all children should have a written action plan for at home and childcare

Reliever treatment

Reliever Treatment

• SABA (salbutamol):
  • All children should be prescribed SABA with spacer
  • Encourage children to carry their inhaler and spacer at all times
  • Dose: salbutamol 100 microg MDI, 6-12 puffs (via spacer +/- mask)
  • Monitoring:
    • Check the number of canisters used between each review (>3 a year is high risk)
    • Encourage dose-tracking (e.g., check dose counter if available) to avoid premature disposal or using empty canisters

Step 1: SABA Only

• Criteria for SABA-only use:
  • No treatment for exacerbations (systemic corticosteroid or hospital presentation) in the past 12 months
  • Infrequent symptoms (refer to symptom frequency table)
  • No other contributing factors (e.g., smoking in household, obesity, social risk factors)
• Note: Most other children will require maintenance treatment (preventer)

Maintenance Treatment (Preventers)

• Step 2: Low Dose ICS via Spacer (and reliever as needed):
  • Ciclesonide 80 microg once daily or Fluticasone 50 microg twice daily
    • Ciclesonide advantages: daily dosing, lower side effect profile, PBS subsidised (lower out-of-pocket costs), but not all spacer devices are compatible
  • Montelukast oral tablet:
    • Alternative first-line preventer or adjunct to ICS in children needing further control
    • Montelukast 5 mg once daily
    • Consider using as an ICS alternative if significant parental concern about steroids or if MDI + spacer use is difficult
    • Side effects: 1 in 6 children may develop agitation, sleep disturbance, and altered mood. If this occurs, cease medication to see if symptoms resolve
• Step 3: Moderate Dose ICS OR Low Dose ICS + Montelukast OR ICS/LABA (and reliever as needed):
  • Moderate dose ICS: Fluticasone 100 microg twice daily or Ciclesonide 160 microg once daily
  • ICS/LABA:
    • Budesonide/formoterol MDI 100 microg/3 microg, 2 puffs twice daily
    • DPI 200 microg/6 microg, one inhalation twice daily
• Step 4: Moderate Dose ICS + Montelukast OR ICS/LABA + Montelukast OR Expert Referral:
  • Refer for expert advice if asthma is not responding to treatment

Additional Measures

• Environmental Considerations:
  • Achieve good asthma control to reduce the need for SABA
  • Switch to DPI when possible (suitable for many children from about age 6)
  • Prescribe 1 puff of a stronger dose preventer instead of 2 puffs of a weaker dose
  • Use once-daily medication (e.g., ciclesonide)
  • Implement dose tracking
  • Refer to additional resources for more information on green prescribing

Stepping up or down according to response
The degree of symptom control, irrespective of the current regimen, informs whether changes need to be made to the preventer treatment

	Good control (All of)	Partial control (One or two of)	Poor control (Three or more of)
Daytime symptoms	≤2 days per week	>2 days per week	>2 days per week
Need for reliever*	≤2 days per week	>2 days per week	>2 days per week
Limitation to activity	none	present	present
Nighttime symptoms (or on waking)	none	present	present

* Reliever frequency does not include doses taken prophylactically before exercise

• Start at Step 1 and step up after 6 weeks if further control required
• Always check correct technique and adherence prior to stepping up. Consider alternate diagnoses
• Good control for a period of approximately 3 months suggest preventer treatment could be stepped down

• Continue the lowest treatment that controls symptoms
• Only cease treatment after a period of 6 months symptom-free and review 4-6 weeks after stepping down
• Consider ongoing management of triggers and seasonal factors when stepping treatment up or down

Approach to asthma not responding to treatment

• Review if asthma is correct diagnosis
• Review adherence
• Review inhaler technique
• Consider contributing factors (see above in assessment)

For children who are nearing adolescence (ie 10-11 years old) and having difficulty with their asthma control, it is worth considering ICS-formoterol MART. See Asthma in adolescents (12 years and over)

• This can be prescribed as either budesonide/formoterol DPI (Turbuhaler®) 200 microg/6 microg or budesonide/formoterol MDI (Rapihaler®) 100 microg/3 microg
• DPI is preferred for those with adequate technique
• This may be prescribed “off label” or via private script