All Wales Paediatric Asthma Management and Prescribing Guideline

Overview

This Guidelines summary covers All Wales Therapeutics and Toxicology Centre recommendations on managing paediatric asthma, including prescribing information. This incorporates treatment and inhaler recommendations by age, assessment of asthma control and exacerbation risk, referral thresholds, and information about the environmental impact of poor asthma control.

Reflecting on Your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Core Principles

• Review peak flow, inhaler technique, triggers, vaping, smoking, and secondhand smoke exposure at each review
• Where possible, enrol the patient on the Asthmahub for Parents app
• Review digital control record on the patient's app profile at each review
• Update the patient's digital asthma action plan and medication on the patient's app profile at each review
• Document your healthcare interaction on the patient's app profile at each review.

Treatment and Inhaler Principles

• Use paediatric low-, moderate-, and high-dose inhaled corticosteroids (ICSs) in children under 12 years of age
• Use adult low-, moderate-, and high-dose ICS in children aged 12 years and over
• All metered-dose inhalers (MDIs) should be used with a spacer (Aerochamber Plus series recommended). Mouthpiece spacers are more efficient than mask spacers. Children over 3 years of age should be able to use a mouthpiece spacer even when unwell
• Consider dry-powder inhalers (DPIs) in children aged 6 years and over, and trial a DPI as first line in children aged 12 years and over
• For children already on MDIs, consider 'switch from six' from MDI to DPI according to patient preference. Ensure adequate technique training. Review response to any change of therapy within 3 months
• Prescribe by brand to ensure consistent device
• ICS and long-acting beta-agonist (LABA) therapies must always be administered in a combination inhaler
• Prescribe a short-acting beta-agonist (SABA) MDI and spacer for emergency use to all children.

Template for Asthma Review

Treatment Recommendations by Age

Algorithm 1: Treatment Recommendations by Age

General Principles of Management

The aims of asthma management are to:

• control symptoms allowing normal levels of activity, undisturbed sleep and full school attendance
• prevent exacerbations
• maintain normal lung function
• use minimum therapy necessary.

Well-Controlled Asthma

• The Global Institute for Asthma (GINA) 2022 strategy report defines good symptom control as:^[A]
  • daytime symptoms less than three times a week
  • no limitations of daily activities, including exercise
  • no nocturnal symptoms or awakening because of asthma
  • reliever treatment required less than three times a week
• In addition to uncontrolled symptoms, the GINA 2022 strategy report identifies the following risk factors for future exacerbations:^[A]
  • previous exacerbation, particularly within the last 12 months
  • poor adherence and inhaler technique
  • high SABA use
  • poor lung function (especially forced expiratory volume in the first second <60%)
  • smoking and vaping exposure and air pollution
  • comorbid allergic disease
  • poverty.

Assessing Asthma Control and Risk of Exacerbation

Helpful Questions to Clarify Asthma Control

1. Have you had daytime symptoms of asthma?
2. Have you had difficulty sleeping because of asthma?
3. Has your asthma interfered with normal activities at school, like playing sports?
4. How many times a week are you taking your reliever therapy?

Helpful Questions to Clarify Risk of Future Exacerbations

1. Have you picked up your asthma prescription this month?
2. Are you taking your preventer inhaler regularly?
3. Have you had your inhaler technique checked recently?
4. Have you visited your GP, accident and emergency department, or been admitted to hospital because of asthma this month?
5. Have you required a course of prednisolone for asthma this month?
6. Do you or anyone in your household smoke or vape?

Perform Peak Flow at Every Consultation Over 5 Years of Age

• Checking peak flow in clinic will help you understand whether your patient has well-controlled asthma at the moment. The value should be assessed as a percentage of the best ever peak flow that the child has performed. The peak flow can be categorised into green, amber, or red zones depending on percentage of best ever blow.

Table 1: Peak Flow Categorisation

• If your patient does not know their best ever blow, it should be available on their Asthmahub app, which you can review together (see full guideline for further information).

Treatment Trial and Referral Thresholds

Table 2: ICS Categorisation (Beclometasone Dipropionate Equivalent)

Trial of Treatment with ICS Therapy (All Age Groups)

1. Commence paediatric moderate dose ICS (200 mcg BD beclometasone dipropionate)
2. Review response at 8 weeks.

Patients Under 6 Years of Age

• It can be difficult to make a diagnosis of asthma in children with preschool wheeze, given that there are no objective tests that can be used to confirm the diagnosis. Recurrent wheeze in this age group may or may not be responsive to beta-agonists or ICSs
• Poor response to beta-agonists in young children with wheezing may reflect a relatively small contribution to airway narrowing from smooth muscle bronchoconstriction, with airway obstruction predominantly due to mucous production and airway oedema. There is no evidence that ipratropium bromide works better than salbutamol in this age group
• Other atopic disease, a family history of atopy, and a raised blood eosinophil count >0.2 x 10⁹/l (if available) may be helpful in identifying those children with eosinophilic inflammation who are more likely to respond to asthma therapies at a young age
• Short-lived, occasional wheeze may be managed with SABA monotherapy and regular review
• All children with persistent symptoms (using inhaled beta-agonist at least three times per week, symptomatic at least three times per week, or waking 1 night a week with wheeze symptoms) should be given an 8-week trial of treatment with a paediatric moderate-dose ICS
• All children aged over 3 years with recurrent episodic symptoms (including viral-associated symptoms) should be suspected of having asthma and offered an 8-week trial of treatment with a paediatric moderate-dose ICS
• If a trial of treatment with an ICS is positive, the child should be commenced on a paediatric low-dose ICS as maintenance therapy (that is, a drop in ICS dose from the trial of treatment dose)
• In children aged under 6 years, escalation of therapy in primary care should be limited to a paediatric low-dose ICS plus leukotriene receptor antagonist (LTRA), before considering referral to secondary care for reassessment
• Children aged under 4 years should be referred from secondary to specialist or tertiary asthma care if symptoms remain severe or frequent on a paediatric moderate-dose ICS and LTRA
• Children aged 4–6 years should be referred from secondary to specialist or tertiary asthma care if symptoms remain severe or frequent on a paediatric moderate-dose ICS/LABA and LTRA
• A SABA MDI and spacer (Aerochamber Plus series recommended) should be prescribed to all patients for emergency treatment.

Patients Aged 6–11 Years

• Short-lived, occasional wheeze may be managed with SABA monotherapy and regular review. There should be a low threshold for commencing maintenance therapy
• All children aged 6–11 years with persistent symptoms (using inhaled beta-agonist at least three times per week, symptomatic at least three times per week, or waking 1 night a week with wheeze symptoms) should be commenced on maintenance therapy
• All children aged 6–11 years with recurrent episodic symptoms should be commenced on maintenance therapy
• All children aged 6–11 years who have had an asthma attack requiring corticosteroids in the last 24 months should be commenced on maintenance therapy
• First-line maintenance therapy is a paediatric low-dose ICS
• LTRAs should not be used as monotherapy in this age group
• In children aged 6–11 years, escalation of therapy in primary care should be limited to a paediatric low-dose ICS/LABA and LTRA before considering referral to secondary care for reassessment
• Children aged 6–11 years should be referred from secondary to specialist or tertiary care if symptoms remain severe or frequent on a paediatric moderate-dose ICS/LABA and LTRA
• DPIs should be considered in all children aged 6 years and over, given that there are licensed medications. Ensure adequate resources are available to deliver inhaler technique training. DPIs:
  • can be taken effectively with appropriate training
  • increase medication prescribing choice in an age group where few choices exist
  • offer the patient ease-of-use advantages that they may prefer
  • have a lower environmental impact compared with MDIs
• Consider switching from an MDI to a DPI from the age of 6 years in patients with well-controlled asthma already on maintenance therapy ('switch from 6'), and according to patient technique and preference. Ensure adequate resources are available to deliver inhaler technique training. Review response to any change of therapy within 3 months
• A SABA MDI and spacer (Aerochamber Plus series recommended) should be prescribed to all patients for emergency treatment.

Patients Aged 12 Years and Over

• Short-lived, occasional wheeze may be managed with SABA monotherapy and regular review. There should be a low threshold for commencing maintenance therapy
• All children aged 12 years and over, with persistent symptoms (using inhaled beta-agonist more than 3 times per week, symptomatic more than 3 times per week, or waking 1 night a week with wheeze symptoms) should be commenced on maintenance therapy
• All children aged 12 years and over with recurrent episodic symptoms should be commenced on maintenance therapy
• All children aged 12 years and over, who have had an asthma attack requiring corticosteroids in the last 24 months, should be commenced on maintenance therapy
• First-line maintenance therapy is an adult low-dose ICS
• LTRAs should not be used as monotherapy in this age group
• In children aged 12 years and over, escalation of therapy in primary care should be limited to an adult low-dose ICS/LABA and LTRA before considering referral to secondary care for reassessment
• Adult low-dose ICS/LABA may be delivered as fixed-dose ICS/LABA or in a MART regime
• Children aged 12 years and over should be referred from secondary to specialist or tertiary care if symptoms remain severe or frequent on an adult moderate-dose ICS/LABA and LTRA
• An adult moderate-dose ICS/LABA may be delivered as fixed-dose ICS/LABA or in a MART regime
• DPIs are the preferred choice for children aged 12 years and over, given that they offer options for MART therapy and once-daily dosing, and have less environmental impact compared with MDIs. Consider switching from an MDI to a DPI in patients with well-controlled asthma already on maintenance therapy according to patient preference. Ensure adequate resources are available to deliver inhaler technique training. Review response to any change of therapy within 3 months
• A SABA MDI and spacer (Aerochamber Plus series recommended) should be prescribed to all patients for emergency treatment.

Inhaler Device Selection

Full instructions on asthma inhalers, dosing, licences, and age applicability, as well as instruction on inhaler technique for specific devices can be found on the RightBreathe website: www.rightbreathe.com. The NHS Wales Asthmahub for Parents app also contains educational videos on inhaler technique. 

For information on inhaler device selection and MART therapy, refer to the full guideline.

Stepping Up, Stepping Down, and Reassessing Treatment Strategy

Stepping Up

• An assessment of poor asthma control should trigger consideration of escalating therapy
• Modifiable factors that may influence asthma control should be discussed whenever escalation of therapy is considered, including inhaler technique, compliance, exposure to smoking and vaping, and management of triggers
• Treatment for comorbidities, especially atopic disease, should be optimised
• In young children, reflection on whether symptoms are responsive to anti-asthma therapy is important before escalation of therapy
• Any change in therapy should be reassessed within 3 months.

Stepping Down

• All asthma guidelines recommend a stepwise approach, including the need to consider stepping down therapy once control is achieved and maintained in order to minimise treatment side effects
• Reductions in asthma therapy may be considered if a patient has had complete asthma control over a 3-month period. A decision to step down should consider how difficult it was to achieve stability and also whether previous step-down attempts have resulted in exacerbations. Seasonal variation in symptoms should also be considered.

Reassessing Treatment Strategy Between Age Group Classifications

• As children progress from one age group to the next at 6 years and 12 years:
  • consider available inhaler devices and regimens now available to them
  • discuss new options and potential advantages of switching to a new regimen
  • consider patient preference and technique ability
  • review response to any change of therapy within 3 months.

National Steroid Treatment Card

• A National Steroid Treatment Card (in Wales) or a National Steroid Emergency Card (in England) should be given to all patients prescribed paediatric high-dose or adult moderate-dose ICSs (>800 mcg beclometasone dipropionate equivalent)
• In addition, a National Steroid Treatment Card should be considered if the patient is using other glucocorticoids (including potent/very potent topical glucocorticoids, regular nasal glucocorticoids) alongside paediatric moderate dose inhaled steroids (400 mcg beclometasone dipropionate equivalent)
• More information can be found at the Welsh Endocrine and Diabetes Society website: www.weds-wales.co.uk and the Society for Endocrinology: www.endocrinology.org/clinical-practice/clinical-guidance/adrenal-crisis.

For information on the decarbonisation policy in Wales, self-management via the NHS Wales Asthmahub for Parents app, and the All Wales ICST education platform, refer to the full guideline.

Footnote

[A] This information derives from the GINA 2022 strategy report. This report has since been updated and superseded by the GINA 2023 strategy report, which should be referred to for further information.