Asthma in children

For children 12 years and over — see Asthma in adults 

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

Do

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

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

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

• 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

* 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

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

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

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