Pharmacological management in children under 5

Asthma pathway (BTS, NICE, SIGN) [SIGN 244]

This content is from the BTS, NICE and SIGN guideline - Asthma: diagnosis, monitoring and chronic asthma management (SIGN 245), 2024.

These recommendations are for children under 5 with newly suspected or confirmed asthma, or with asthma symptoms that are uncontrolled on their current treatment.

See also algorithm E for a summary of the pharmacological management of asthma in children under 5.

 

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1.9.1 Consider an 8 to 12 week trial of twice-daily paediatric low-dose inhaled corticosteroid (ICS) as maintenance therapy (with a short-acting beta2 agonist [SABA] for reliever therapy) in children under 5 with suspected asthma and:

  • symptoms at presentation that indicate the need for maintenance therapy (for example, interval symptoms in children with another atopic disorder), or
  • severe acute episodes of difficulty breathing and wheeze (for example, requiring hospital admission, or needing 2 or more courses of oral corticosteroids).

[BTS/NICE/SIGN 2024]

 

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1.9.2 If symptoms do not resolve during the trial period, take the following sequential steps:

  • check inhaler technique and adherence
  • check whether there is an environmental source of their symptoms (for example mould in the home, cold housing, smokers or indoor air pollution)
  • review whether an alternative diagnosis is likely.

If none of these explain the failure to respond to treatment, refer the child to a specialist in asthma care.

[BTS/NICE/SIGN 2024]

 

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1.9.3 Consider stopping ICS and SABA treatment after 8 to 12 weeks if symptoms are resolved. Review the symptoms after a further 3 months.

[BTS/NICE/SIGN 2024]

 

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1.9.4 If symptoms resolve during the trial period, but then:

  • symptoms recur by the 3-month review, or
  • the child has an acute episode requiring systemic corticosteroids or hospitalisation, restart regular ICS (begin at a paediatric low dose and titrate up to a paediatric moderate dose if needed) with SABA as needed and consider a further trial without treatment after reviewing the child within 12 months.

[BTS/NICE/SIGN 2024]

 

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1.9.5 If suspected asthma is uncontrolled in children under 5 on a paediatric moderate dose of ICS as maintenance therapy (with SABA as needed), consider a leukotriene receptor antagonist (LTRA) in addition to the ICS. Give the LTRA for a trial period of 8 to 12 weeks (unless there are side effects), then stop it if it is ineffective.

[BTS/NICE/SIGN 2024]

November 2024: Follow the MHRA safety advice on the risk of neuropsychiatric reactions in people taking montelukast.

 

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1.9.6 If suspected asthma is uncontrolled in children under 5 on a paediatric moderate dose of ICS as maintenance therapy and a trial of an LTRA has been unsuccessful or not tolerated, stop the LTRA and refer the child to a specialist in asthma care for further investigation and management.

[BTS/NICE/SIGN 2024]

 

           

Rationale and impact

Why the committee made the recommendation

Evidence was available for 5 treatment options: SABA alone used as needed; regular ICS plus SABA as needed; SABA/ICS combination inhaler used as needed; regular SABA/ICS combination inhaler; and regular montelukast. The evidence did not encompass all possible comparisons of the 5 options, but overall, those that included the use of an ICS clearly showed greater benefits than those without an ICS, and regular ICS (either ICS alone or ICS/SABA) was superior to intermittent ICS/SABA. The most important benefits of regular ICS were seen in reducing exacerbations or hospital admissions. There was no advantage to using regular ICS/SABA instead of regular ICS alone.

In making recommendations for this age group, the committee took into account the difficulty of making a firm diagnosis of asthma. Episodes of cough and wheezing can occur with recurrent viral infections and be difficult to distinguish from asthma, and there are concerns about treating young children with long-term ICS when they may not need them.

The committee were aware of evidence outside the review of diagnostic tests showing that asthma is more likely than recurrent viral wheeze when the episodes are frequent or severe, when they occur in the absence of other signs of viral illness and when the child shows other evidence of atopy. They made recommendations on the staged introduction of ICS as part of the diagnostic process in infants. They agreed that young children with recurrent wheeze and features suggesting asthma should be treated empirically with a low dose of ICS for 8 to 12 weeks, and then this can be stopped. If symptoms soon re-appear after stopping ICS, this suggests that the ICS was beneficial rather than the improvement being due to the natural remission of a viral episode. Once the presence of asthma is established with reasonable certainty the committee agreed that regular paediatric low-dose ICS should be restarted, with subsequent steps added if needed.

As diagnosis in this age group is so difficult, the committee agreed that thresholds for referral to an asthma specialist should be low.

How the recommendation might affect practice

The recommendations for treatment of newly diagnosed asthma in children are in line with current NICE recommendations.

 

Full details of the evidence and the committee’s discussion are in evidence review P: drug classes for initial asthma management.