Asthma – child aged 1–5 years

gathered from https://www.asthmahandbook.org.au/ -v2.0

Asthma in children is defined clinically as a combination of variable respiratory symptoms (e.g., wheeze, shortness of breath, cough, and chest tightness) and excessive variation in lung function, which indicates variable airflow limitation greater than that seen in healthy children.

Key Points

• No single reliable test or standardized diagnostic criteria for asthma
• Diagnosis is based on:
  • History
  • Physical examination
  • Considering other diagnoses
  • Clinical response to a treatment trial with an inhaled short-acting beta2 agonist reliever or preventer

Age-specific Diagnostic Considerations

Infants (0–12 months)

• Asthma should not be diagnosed in infants less than 12 months old.
  • Wheezing in this age group is most commonly due to acute viral bronchiolitis or small/floppy airways.
  • Infants with clinically significant wheezing should be referred to a paediatric respiratory physician or paediatrician.

Preschool Wheeze (1–5 years)

• Challenges in diagnosing asthma in children aged 1–5 years:
  • Episodic respiratory symptoms (e.g., wheezing and cough) are very common, especially in children under 3 years.
  • Objective lung function testing by spirometry is usually not feasible.
  • A high proportion of children who respond to bronchodilator treatment do not go on to have asthma in later childhood.

Children Aged 6–11 Years

• Diagnosis supported by documentation of variable expiratory airflow limitation:
  • School-aged children able to perform spirometry can have their diagnosis supported by evidence of variable airflow limitation.

Adolescents

• Diagnosis similar to adults:
  • In older adolescents, the guidance on the diagnosis of asthma in adults generally applies.

Summary Table

Age Group	Key Points	Diagnostic Approach
Infants (0–12 months)	– Asthma should not be diagnosed. – Wheezing often due to viral bronchiolitis or small/floppy airways. – Referral to paediatric respiratory physician or paediatrician recommended.	– History and physical examination. – Consider other diagnoses. – Referral for significant wheezing.
Preschool Wheeze (1–5 years)	– Difficult to diagnose asthma with certainty. – Episodic symptoms common. – Spirometry usually not feasible. – Many children outgrow symptoms.	– History and physical examination. – Consider other diagnoses. – Clinical response to bronchodilator.
Children (6–11 years)	– Diagnosis supported by variable expiratory airflow limitation. – Spirometry can be performed.	– History and physical examination. – Spirometry to document airflow limitation. – Clinical response to treatment.
Adolescents	– Follow adult guidelines for diagnosis.	– History and physical examination. – Spirometry to document airflow limitation. – Clinical response to treatment.

References

• National Asthma Council Australia. A working definition of asthma.
• British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS/SIGN, Edinburgh, 2012.
• Respiratory Expert Group, Therapeutic Guidelines Limited. Therapeutic Guidelines: Respiratory, Version 4. Therapeutic Guidelines Limited, Melbourne, 2009.

History and Physical Examination for a Wheezing Child (Aged 1–5 Years)

Confirming Wheezing

Method	Details
Observe the child	If possible, see the child during a bout of wheezing.
Recording by parents/carers	Ask parents/carers to make an audio or video recording of noisy breathing.
Show reference video	Show parents/carers a video of true wheezing (e.g., Royal Children’s Hospital Melbourne’s asthma video from 2:52 to 3:52).

History Taking

Aspect	Details
Current Symptoms	Note present symptoms and their descriptions.
Symptom Pattern	Frequency and timing of wheezing episodes. <br> Whether wheezing occurs only with viral colds or at other times (e.g., during play or laughing).
Appearance During Episodes	Ask if the child’s chest appears sucked in during breathing episodes.
Child’s General Behavior	Assess if the child is alert, active, socially responsive, and plays with other children.
Home Environment	Investigate exposure to smoke, pets, and other potential allergens.
Allergies	Inquire about allergies, atopic dermatitis (eczema), and allergic rhinitis.
Family History	Check for a family history of asthma and allergies.

Physical Examination

Aspect	Details
Growth Parameters	Measure height and weight, compare with age norms.
Chest Inspection	Look for chest deformities.
Upper Airway Examination	Check for signs of allergic rhinitis (swollen turbinates, nasal crease, mouth breathing, dark swollen areas under eyes) or polyps.
Chest Auscultation	Listen to lung sounds for wheezing or other abnormalities.
Fingers	Inspect for clubbing, indicative of chronic pulmonary conditions.
Skin Examination	Look for atopic dermatitis.

Differential Diagnoses

Finding	Notes
Persistent cough without wheeze/breathlessness	Unlikely to be asthma.
Onset of signs from birth/early life	Suggests congenital or chronic conditions (e.g., cystic fibrosis, chronic lung disease of prematurity).
Family history of unusual chest disease	Enquire thoroughly before diagnosing asthma.
Severe upper respiratory tract disease	Consider specialist assessment.
Unilateral wheeze	Suggests inhaled foreign body.
Systemic symptoms (e.g., fever, weight loss)	Consider alternative systemic disorders.
Feeding difficulties (e.g., choking, vomiting)	Suggests aspiration; requires specialist assessment.
Inspiratory noises (e.g., stridor)	Acute stridor indicates croup.
Persistent voice abnormality	Suggests upper airway disorder.
Finger clubbing	Indicates chronic lung disease (e.g., cystic fibrosis).
Chronic wet/productive cough (>4 weeks)	Suggests chronic conditions (e.g., bronchiectasis, cystic fibrosis).
Focal lung signs	Suggests pneumonia.
Nasal polyps in children <5 years	Suggests cystic fibrosis.
Severe chest deformity	Requires consideration of other diagnoses.
Obvious breathing difficulty (at rest or night)	Specialist assessment needed.
Recurrent pneumonia	Specialist assessment required.

Wheeze Definition

Aspect	Details
Characteristics	High-pitched sound during inspiration or expiration due to intrathoracic airway narrowing.
Differentiating Sounds	Inspiratory sounds (e.g., rattling, stridor) are not wheeze.
Parental Reports	Parental reports often include various noises; confirmation via stethoscope is essential.

Epidemiology and Prognosis

Aspect	Details
Prevalence	One-third of children have wheezing before age 3; half by age 6.
Asthma Correlation	Wheezing is common in early childhood but not necessarily indicative of asthma. Only one-third of preschoolers with recurrent wheezing have asthma at age 6.
Atopy and Asthma	Asthma often linked with atopic conditions (eczema, allergic rhinitis). Family history of atopy increases likelihood.

Recommendations for Clinicians

Aspect	Details
Use of Technology	Hand-held devices and smartphone applications for detecting wheeze are not recommended due to insufficient evidence and potential for mismanagement.
Long-Term Patterns	Early childhood wheezing phenotypes can only be identified retrospectively; current tools for predicting asthma have limited clinical value.

Classification of Wheezing Phenotypes

System/Source	Phenotype	Description
Tucson Children’s Respiratory Study	Transient wheeze	Wheezing starts before age 3 and disappears by age 6.
	Persistent wheeze	Wheezing continues until or after age 6.
	Late-onset wheeze	Wheezing starts after age 3.
Avon Longitudinal Study of Parents and Children	Transient early wheeze	Wheezing mainly before 18 months, disappearing by age 3.5.
	Prolonged early wheeze	Wheezing from 6 months to 4.5 years, disappearing before age 6.
	Intermediate-onset wheeze	Wheezing begins between 18 months and 3.5 years.
	Late-onset wheeze	Wheezing begins after age 3.5 years.
	Persistent wheeze	Wheezing starts after 6 months and continues through primary school.

References

1. Comberiati P, et al. (2017). “How much asthma is atopic in children?” Front Pediatr.
2. Turner S. (2017). “Gene-environment interactions-what can these tell us about the relationship between asthma and allergy?” Front Pediatr.
3. van der Hulst AE, et al. (2007). “Risk of developing asthma in young children with atopic eczema.” J Allergy Clin Immunol.

Differential Diagnosis for Wheezing in Children Aged 1–5 Years

Features Increasing or Reducing the Probability of Asthma

Asthma More Likely	Asthma Less Likely
More than one of: wheeze, difficulty breathing, chest tightness, cough	Symptoms only occur with colds, not between colds
Symptoms recur frequently	Isolated cough without wheeze or difficulty breathing
Symptoms worse at night and early morning	History of moist cough
Symptoms triggered by exercise, pets, cold air, damp air, emotions, laughing	Dizziness, light-headedness, or peripheral tingling
Symptoms occur without a cold	Repeatedly normal chest examination when symptomatic
History of allergies (e.g., allergic rhinitis, atopic dermatitis)	Normal spirometry when symptomatic (if child can perform spirometry)
Family history of allergies	No response to a trial of asthma treatment
Family history of asthma	Clinical features suggest an alternative diagnosis
Widespread wheeze heard on auscultation
Symptoms respond to a treatment trial of reliever, with or without a preventer
Spirometry shows increased lung function in response to a rapid-acting bronchodilator
Spirometry shows increased lung function in response to a treatment trial with inhaled corticosteroid (where indicated)

Investigating Cough as a Prominent Symptom

• Follow the current Australian Cough Guidelines.

Consider Alternative Diagnoses and Comorbidities

Category	Conditions
Congenital Conditions	Structural airway problems (e.g., tracheomalacia, bronchopulmonary dysplasia, vascular ring anomaly), cystic fibrosis, immune deficiency, primary ciliary dyskinesia, congenital heart disease
Infective Conditions	Bronchiolitis (infants <12 months), laryngotracheobronchitis (croup), chronic rhinosinusitis, recurrent respiratory tract infections, chronic suppurative lung disease (consider protracted bacterial bronchitis or bronchiectasis)
Acquired Conditions	Inhaled foreign body, gastro-oesophageal reflux, recurrent aspiration, tumour, pulmonary oedema

Conditions Characterized by Cough

• Pertussis (whooping cough)
• Post-viral cough
• Cystic fibrosis
• Airway abnormalities (e.g., tracheobronchomalacia)
• Protracted bacterial bronchitis in young children
• Habit-cough syndrome

Conditions Characterized by Wheezing

• Upper airway dysfunction
• Inhaled foreign body causing partial airway obstruction
• Tracheobronchomalacia

Conditions Characterized by Difficulty Breathing

• Hyperventilation
• Anxiety
• Breathlessness on exertion due to poor cardiopulmonary fitness
• Upper airway dysfunction

Important Findings and Notes

Finding	Notes
Persistent cough without wheeze/breathlessness or systemic disease	Unlikely to be due to asthma
Onset of signs from birth or very early in life	Suggests congenital conditions (e.g., cystic fibrosis)
Family history of unusual chest disease	Should be enquired about before diagnosing asthma
Severe upper respiratory tract disease	Specialist assessment should be considered
Crepitations on chest auscultation that do not clear on coughing	Suggest serious lower respiratory tract condition (e.g., pneumonia)
Unilateral wheeze	Suggests inhaled foreign body
Systemic symptoms (e.g., fever, weight loss, failure to thrive)	Suggest an alternative systemic disorder
Feeding difficulties (e.g., choking, vomiting)	Suggests aspiration; specialist assessment required
Inspiratory upper airway noises (e.g., stridor, snoring)	Acute stridor suggests tracheobronchitis (croup)
Persistent voice abnormality	Suggests upper airway disorder
Finger clubbing	Suggests cystic fibrosis or bronchiectasis
Chronic wet/productive cough (>4 weeks)	Suggests chronic conditions (e.g., bronchiectasis)
Focal lung signs	Suggests pneumonia
Nasal polyps in children <5 years	Suggests cystic fibrosis
Severe chest deformity	Requires consideration of other diagnoses
Obvious breathing difficulty (at rest or night)	Specialist assessment needed
Recurrent pneumonia	Specialist assessment required

Additional Information on Cough and Asthma Relationship in Children

• Misdiagnosis Risk:
  • Misdiagnosis of nonspecific cough as asthma can lead to overtreatment.
  • Chronic cough without other features of asthma is unlikely due to asthma.
• Chronic Cough:
  • Often due to protracted bacterial bronchitis, post-viral cough, or exposure to tobacco smoke and pollutants.
• Preschool Children:
  • Recurrent cough without other signs likely due to recurrent viral bronchitis.
• Older Children:
  • Chronic cough may be due to asthma if associated with other asthma features like expiratory wheeze or exercise-related breathlessness.

References

1. Weinberger M, Abu-Hasan M. “Pseudo-asthma: when cough, wheezing, and dyspnea are not asthma.” Pediatrics 2007; 120: 855-64.

Recommendations

• Use appropriate guidelines to investigate and manage chronic cough.
• Consider alternative diagnoses when asthma treatment is ineffective or symptoms suggest other conditions.
• Avoid reliance on parental reports alone; confirm wheezing with a stethoscope.
• Refer to specialists for persistent, atypical, or severe symptoms.

Further Investigations for Wheezing in Children Aged 1–5 Years

Recommendations

1. Allergy Tests
   • Consider allergy tests (skin prick test or specific IgE assay) for common aeroallergens for children with recurrent wheezing when the results might guide you in either:
     • Assessing the prognosis:
       • Presence of allergies in preschool children increases the probability that the child will have asthma at primary school age.
     • Managing symptoms:
       • Advising parents/carers about management if avoidable allergic triggers are identified.
2. Chest X-ray
   • Arrange chest X-ray if the child has unusual respiratory symptoms or if wheezing is localized.
   • Routine chest X-ray is not recommended in the investigation of asthma symptoms in children.
3. Exhaled Nitric Oxide
   • Measurement of exhaled nitric oxide is not recommended as a diagnostic test for asthma in routine clinical practice.
4. Microbiological Investigations
   • Routine microbiological investigations are not recommended in the investigation of symptoms that suggest asthma.
5. Specialist Referral
   • Offer referral to a specialist for further assessment and investigation if:
     • The diagnosis is unclear.
     • A serious condition cannot be ruled out.

Additional Information

1. Asthma Types
   • Asthma can be atopic or non-atopic.
     • Atopic asthma:
       • Characterized by eosinophilic airway inflammation associated with sensitization to aeroallergens (positive skin prick test or specific IgE on serology).
       • More common form in children.
2. Links between Asthma and Atopy
   • Many children with asthma are also atopic and have eczema, hay fever, or food allergies, but not all children with atopy develop asthma.
   • Eczema and allergic rhinitis are risk factors for developing asthma.
   • Parental atopy has been identified as a risk factor for asthma in several studies, though the strength of the association differs between populations.
3. Family History
   • A family history of atopy or asthma, or a personal history of atopy, increases the probability that wheezing in children is due to asthma.
4. Association with Allergic Rhinitis
   • The association between allergic rhinitis and asthma may reflect common allergic causes rather than a causal link.
   • Few studies have examined gene-environment interactions for asthma and atopy in the same population.

Specific Tests and Their Roles

1. Skin-Prick Testing
   • Recommended for guiding management if the child is sensitized to avoidable aeroallergens.
   • Risk factors for anaphylaxis during skin prick testing include:
     • Uncontrolled or unstable asthma
     • Age less than 6 months
     • Widespread atopic dermatitis
   • Precaution:
     • Perform skin prick testing in specialist practices for children under 2 years and children with severe or unstable asthma.
2. Total Serum IgE Testing
   • Poor predictor of allergies or asthma in children aged 0–5 years.
3. Specific Serum IgE Testing
   • Children aged 1–4 years with raised specific IgE for inhaled allergens (e.g., house dust mite, cat dander) are more likely to have asthma at age 6.
   • Sensitization to hen’s egg at the age of 1 year (specific IgE) is a strong predictor of allergic sensitization to inhaled allergens at age 3 years.

When to Consider Further Investigations

• Symptoms are present from birth.
• Airway obstruction is abnormally severe.
• Recovery is very slow or incomplete (resulting in prolonged or repeated hospital admission in the first few years of life).
• Episodes continue in the absence of a viral infection.
• Parents are very anxious.

Summary Table

Investigation	Indication	Notes
Allergy Tests (skin prick or specific IgE)	Recurrent wheezing	Guide prognosis and management
Chest X-ray	Unusual respiratory symptoms or localized wheezing	Not routinely recommended for asthma symptoms
Exhaled Nitric Oxide	Not recommended for routine asthma diagnosis	–
Microbiological Investigations	Not recommended for routine asthma diagnosis	–
Specialist Referral	Unclear diagnosis or potential serious condition	Further assessment and investigation

Sources

• National Asthma Council Australia’s information paper for health professionals on Inhaler technique for people with asthma or COPD.
• Martinez FD, Wright AL, Taussig LM et al. Asthma and wheezing in the first six years of life. The Group Health Medical Associates. N Engl J Med 1995; 332: 133-8.
• Henderson J, Granell R, Heron J et al. Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function and airway responsiveness in mid-childhood. Thorax 2008; 63: 974-80.
• Brand PL, Baraldi E, Bisgaard H et al. Definition, assessment and treatment of wheezing disorders in preschool children: an evidence-based approach [European Respiratory Society Task Force]. Eur Respir J 2008; 32: 1096-110.

Managing Asthma in Children

Children Aged 0–12 Months

• Wheezing Treatment:
  • Infants less than 12 months old should not be treated for asthma.
  • Wheezing is most commonly due to acute viral bronchiolitis or small/floppy airways.
• Consultation:
  • Obtain advice from a paediatric respiratory physician or paediatrician before administering short-acting beta2 agonists, systemic corticosteroids, or inhaled corticosteroids.
  • Refer infants with clinically significant wheezing requiring hospitalisation or frequent wheezing (e.g., more than once per 6 weeks) to a paediatric respiratory physician or paediatrician.

Children Aged 1–5 Years

• Wheezing and Asthma:
  • Many infants and preschoolers wheeze with viral respiratory infections, even without asthma.
  • Use as-needed salbutamol for children whose wheezing has been shown to be responsive to salbutamol in a treatment trial.
  • A small proportion may need regular preventer treatment for recurrent symptoms between viral respiratory infections.

Children Aged 6 Years and Over

• Diagnosis:
  • Asthma diagnosis is more certain in school-aged children.
  • Reversible expiratory airflow limitation on spirometry supports asthma diagnosis.
• Treatment:
  • All children with asthma need a reliever for asthma symptoms.
  • Regular preventer treatment for frequent intermittent asthma (flare-ups every 6 weeks or more often) or persistent asthma symptoms (daytime symptoms more than once per week or night-time symptoms more than twice per month), and for severe flare-ups, irrespective of frequency.

Treatment Trial for Preschool Wheeze

Recommendations for Children Over 12 Months with Wheezing Episodes

1. Initial Treatment Trial with Short-Acting Beta2 Agonist
   • For children over 12 months old with wheezing episodes associated with increased work of breathing (e.g., intercostal retraction):
     • Consider a trial of treatment with an inhaled short-acting beta2 agonist given as needed.
2. During Consultation (If Child is Wheezing)
   • Administer 2–4 puffs (200–400 microg) of salbutamol via spacer and mask.
   • Note any response to treatment (improvement in work of breathing, respiratory rate, breath sounds, or wheeze).
3. If Positive Response During Consultation
   • Show parents/carers how to administer salbutamol via:
     • Pressurised metered-dose inhaler plus spacer (for older preschool children).
     • Pressurised metered-dose inhaler plus spacer and mask (for infants and children unable to use spacer alone).
   • Instruct parents/carers to:
     • Give 2–4 puffs (200–400 microg) when the child wheezes, and repeat if wheezing recurs.
     • Monitor the child closely for improvement in breathing (e.g., child stops showing signs of increased work of breathing) and report the effects.
4. If Child is Not Wheezing During Consultation
   • Show parents/carers how to administer salbutamol.
   • Ask them to trial this treatment over 1–2 days, starting the next time wheezing occurs, and monitor the response.
   • Repeat the trial if it is inconclusive.
5. Urgent Medical Attention
   • Advise parents/carers to seek urgent medical attention (go to the emergency department or call 000) if:
     • The child needs salbutamol again within 4 hours.
     • Increased work of breathing does not respond to salbutamol.

Summary Table

Step	Action
Initial Trial	Consider a trial with an inhaled short-acting beta2 agonist (salbutamol) for children over 12 months.
During Consultation (If Wheezing)	Administer 2–4 puffs (200–400 microg) of salbutamol via spacer and mask.
Positive Response	Show parents/carers how to use salbutamol with the inhaler and spacer/mask.
	Instruct parents/carers to give 2–4 puffs when the child wheezes, repeat if necessary, and monitor.
If Not Wheezing During Consultation	Show parents/carers how to use salbutamol.
	Ask them to trial treatment over 1–2 days, monitor response, and repeat if inconclusive.
Urgent Medical Attention	Advise seeking urgent medical attention if salbutamol is needed again within 4 hours or no response.

Notes for Parents/Carers

• Positive Response:
  • Use the pressurised metered-dose inhaler plus spacer/mask as demonstrated.
  • Give 2–4 puffs when wheezing occurs, and repeat if wheezing recurs.
  • Monitor the child’s breathing and report the effects.
• No Wheezing During Consultation:
  • Trial the treatment at home over 1–2 days during wheezing episodes.
  • Monitor the response and report the results.
• Urgent Medical Attention:
  • Seek immediate help if the child needs salbutamol again within 4 hours or if there is no improvement in breathing.

Short-Acting Beta2 Agonists for Children Aged 1–5 Years

Infants Under 12 Months:

• Primary Cause of Respiratory Distress:
  • Bronchiolitis is the most likely cause of acute respiratory distress in infants under 12 months.
• Treatment Recommendation:
  • Bronchodilators are not recommended for children under 12 months, consistent with guidelines for managing acute bronchiolitis.

Children Aged 1–5 Years:

• Efficacy of Inhaled Short-Acting Beta2 Agonists:
  • Effective bronchodilators in children aged 1–5 years.
  • May be less effective for wheezing in children under 2 years old.
  • Clinical trials have shown they are more effective than placebo in controlling acute wheeze in children under 2 years, but may not achieve clinically significant improvements.
• Tolerance and Adverse Effects:
  • Generally well tolerated.
  • Adverse effects include muscle tremor, headache, palpitations, and agitation.
  • Serious adverse effects, such as hypokalaemia, reported at very high doses.
  • Oral short-acting beta2 agonists should not be used for asthma treatment in any age group.

Preventer treatment in children aged 1-5

For children aged 12 months and over with a provisional diagnosis of asthma, consider a trial of preventer treatment, if indicated.

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).

Administration of Inhaled Medications for Children Aged 1–5 Years

Training and Supervision:

• Parents and children need training in inhaler technique and in the care and cleaning of inhalers and spacers.
• Children require careful supervision when taking inhaled medicines, especially when using a reliever for acute asthma symptoms.

Types of Inhalers Suitable for Preschool Children:

• Pressurised Metered-Dose Inhalers (pMDI) with Spacer:
  • Essential for proper use as young children cannot coordinate inspiratory effort with actuating the device.
  • Breath-actuated pMDIs are not appropriate for children under 5 years and cannot be used with a spacer.
• Dry-Powder Inhalers:
  • Usually ineffective for preschool children due to insufficient inspiratory airflow generation.

Variability in Drug Delivery:

• Drug delivery is highly variable in young children with any type of inhaler.
• High day-to-day variability in delivered doses might explain fluctuations in effectiveness.

Pressurised Metered-Dose Inhalers Plus Spacers for Relievers:

• More effective during acute wheezing episodes than nebulisers.
• Salbutamol delivered by nebuliser is associated with a greater increase in heart rate compared to pMDI plus spacer.

Administration Recommendations:

• Shake the inhaler, actuate one puff at a time into the spacer, and have the child take 4–6 breaths in and out of the spacer (tidal breathing).
• For children aged 2–7 years, fewer breaths may suffice:
  • 2 breaths for small-volume spacers.
  • 2 breaths for a spacer made from a 500-mL modified soft drink bottle.
  • 3 breaths for a large (Volumatic) spacer.

Face Masks for Infants:

• Effective delivery depends on a tight seal around the face.
• Parents should wash the child’s face after administering inhaled corticosteroids by mask to prevent exposure to eyes and skin.
• Infants are unlikely to inhale enough medicine while crying; patience and skill are required to administer medication effectively.
• Personalizing the spacer and mask (e.g., with stickers or mother’s scent) can help with acceptance.
• Using a spacer with a colored valve allows parents to see the valve move as the child breathes.

Note: Salbutamol inhalers with dose counters are available and can be used to track reliever use.

More Information

• Infants Under 12 Months: Bronchiolitis is the most likely cause of acute respiratory distress. Bronchodilators are not recommended.
• Children Aged 1–5 Years: Inhaled short-acting beta2 agonists are effective but may be less so in children under 2 years old. Generally well tolerated with common adverse effects settling over time.
• Administration of Inhaled Medications: Proper training and supervision are essential. pMDIs with spacers are preferred, and face masks are necessary for effective delivery in young children.

References

1. National Asthma Council Australia. “Inhaler technique for people with asthma or COPD.”
2. Martinez FD, Wright AL, Taussig LM et al. “Asthma and wheezing in the first six years of life.” N Engl J Med 1995; 332: 133-8.
3. Henderson J, Granell R, Heron J et al. “Associations of wheezing phenotypes in the first 6 years of life with atopy, lung function, and airway responsiveness in mid-childhood.” Thorax 2008; 63: 974-80.

Type	Common medicines	Pharmacological class	Function
Manually actuated pressurised metered-dose inhaler (puffer)e.g. Rapihaler, various generic names such as inhaler, CFC-free inhaler and metered aerosol	Airomir Inhaler (salbutamol)	SABA	Reliever
	Asmol CFC-Free Inhaler (salbutamol)	SABA
	Ventolin CFC-Free Inhaler (salbutamol)	SABA
	Symbicort Rapihaler (budesonide plus formoterol)*	ICS + LABA
	Alvesco Metered-dose Inhaler (ciclesonide)	ICS	Preventer
	Flixotide Junior/Flixotide Inhaler (fluticasone propionate)	ICS
	Fluair Inhaler (fluticasone propionate)	ICS
	Fluticasone Cipla Metered-dose Inhaler (fluticasone propionate)	ICS
	Fluticasone Cipla Metered-dose Inhaler (fluticasone propionate)	ICS
	Qvar (beclometasone)	ICS
	Fostair (beclometasone plus formoterol)	ICS + LABA
	Fluticasone and Salmeterol Cipla Inhaler (fluticasone propionate plus salmeterol)	ICS + LABA
	Flutiform Metered-dose Inhaler (fluticasone propionate plus formoterol)	ICS + LABA
	SalplusF Metered-dose Inhaler (fluticasone propionate plus salmeterol)	ICS + LABA
	Seretide MDI (fluticasone propionate plus salmeterol)	ICS + LABA
	Symbicort Rapihaler (budesonide plus formoterol)	ICS + LABA
	Intal CFC-Free Inhaler/IntalForte CFC-Free Inhaler (sodium cromoglycate)	Cromone
	Tilade CFC-Free (nedocromil sodium)	Cromone
	Atrovent Metered Aerosol (ipratropium)	SAMA	Other bronchodilator
Breath-actuated pressurised metered-dose inhalere.g. Autohaler	Airomir Autohaler (salbutamol)	SABA	Reliever
	Qvar Autohaler (beclometasone)	ICS	Preventer
Dry powder inhaler (multi-dose)e.g. Accuhaler, Ellipta, Genuair, Spiromax, Turbuhaler	Bricanyl Turbuhaler (terbutaline sulfate	SABA	Reliever
	Symbicort Turbuhaler (budesonide plus formoterol)*	ICS + LABA
	DuoResp Spiromax (budesonide plus formoterol)*	ICS + LABA
	Arnuity Ellipta (fluticasone furoate)†	ICS	Preventer
	Flixotide Junior / Flixotide Accuhaler (fluticasone propionate)	ICS
	Pulmicort Turbuhaler (budesonide)	ICS
	Breo Ellipta (fluticasone furoate plus vilanterol)†	ICS + LABA
	DuoResp Spiromax (budesonide plus formoterol)	ICS + LABA
	Seretide Accuhaler (fluticasone propionate plus salmeterol)	ICS + LABA
	Symbicort Turbuhaler (budesonide plus formoterol)	ICS + LABA
	Anoro Ellipta (umeclidinium plus vilanterol)‡	LAMA + LABA	Other bronchodilator⚠ Must not be used in asthma or asthma-COPD overlap without an inhaled corticosteroid
	Bretaris Genuair (aclidinium)	LAMA
	Brimica Genuair (aclidinium plus formoterol)	LAMA + LABA
	Incruse Ellipta (umeclidinium)‡	LAMA
	Oxis Turbuhaler (formoterol)	LABA
	Serevent Accuhaler (salmeterol)	LABA
	Trelegy Ellipta (fluticasone furoate plus umeclidinium bromide plus vilanterol trifenatate)†	ICS+LAMA+LABA	Bronchodilator-ICS triple therapy (COPD)
Dry powder inhaler (capsule)e.g. Breezhaler, Handihaler	Onbrez Breezhaler (indacaterol)	LABA	Other bronchodilator⚠ Must not be used in asthma or asthma-COPD overlap without an inhaled corticosteroid
	Seebri Breezhaler (glycopyrronium)	LAMA
	Spiriva Handihaler (tiotropium)	LAMA
	Ultibro Breezhaler (glycopyrronium plus indacaterol)	LAMA + LABA
Mist inhalere.g. Respimat	Spiolto Respimat (tiotropium plus olodaterol)	LAMA + LABA	Other bronchodilator⚠ Must not be used in asthma or asthma-COPD overlap without an inhaled corticosteroid
	Spiriva Respimat (tiotropium)	LAMA

* This medication is classed as a reliever only when maintenance-and-reliever regimen is prescribed. Applies to lower strengths only – does not apply to Symbicort Turbuhaler 400/12 microg, DuoResp Spiromax 400/12 microg or Symbicort Rapihaler 200/6 microg (pressurised metered-dose inhaler).

†Inhaler must be discarded one month after opening.

‡Inhaler must be discarded 6 weeks after opening.