Asthma treatment for under 5s

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway

Diagnostic trial of treatment

Asthma diagnosis is challenging in under 5s. Objective testing is difficult. Diagnosis should be clinical with a trial of treatment.

Step 1 - Trial of paediatric low dose ICS plus SABA

Initial treatment with low dose inhaled steroids (plus SABA)

Preparations:

Inhaler Directions Type Monthly Cost (£) Licensing
Soprobec 50mcg 2 puffs BD MDI 1.66 From age 2
Clenil 50mcg 2 puffs BD MDI 2.22 From age 2

Formulary items in blue. Formulary items which are more environmentally friendly in green.

Plus salbutamol DPI or MDI as reliever

Always prescribe an appropriate sized spacer with any MDI inhaler. Easychamber spacers are the formulary choice

Review after 8-12 weeks

Trial of treatment should be reviewed after 2-3 months.

If treatment has not been effective at step 1:

  • 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.

 

If treatment has been effective:

  • Stop treatment and review again in 3 months
    • If symptoms recur then diagnosis confirmed. Restart at paediatric low dose ICS and titrate as needed as below

Treatment algorithm for under 5s with confirmed asthma

 

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Step 1 - Paediatric low dose inhaled steroid plus SABA

Initial treatment with low dose inhaled steroids (plus SABA)

Preparations:

Inhaler Directions Type Monthly Cost (£) Licensing
Soprobec 50mcg 2 puffs BD MDI 1.66 From age 2
Clenil 50mcg 2 puffs BD MDI 2.22 From age 2

Formulary items in blue. Formulary items which are more environmentally friendly in green.

Plus salbutamol DPI or MDI as reliever

Always prescribe an appropriate sized spacer with any MDI inhaler Easychamber spacers are the formulary choice

Step 2 - Increase to paediatric moderate dose inhaled steroid plus SABA

Step up if uncontrolled on paediatric low dose inhaled steroids (plus SABA)

Preparations:

Inhaler Directions Type Monthly Cost (£) Licensing
Soprobec 100mcg 2 puffs BD MDI 2.89 From Age 2
Clenil 100mcg 2 puffs BD MDI 4.45 From age 2

Formulary items in blue. Formulary items which are more environmentally friendly in green.

Plus salbutamol DPI or MDI as reliever

Always prescribe an appropriate sized spacer with any MDI inhaler Easychamber spacers are the formulary choice

Step 3 - Trial of Montelukast 4mg OD

If uncontrolled on paediatric moderate dose ICS consider trial of Montelukast 4mg daily

Step 4 - Refer for specialist review

If uncontrolled on combination paediatric moderate dose ICS/LABA after trial of montelukast:

  • Review and check compliance and inhaler technique.
  • Check FeNO, if available.
  • Consider referral to specialist.

Editorial Information

Last reviewed: 06/01/2025

Next review date: 06/01/2027

Author(s): Emily Kennedy, Dumfries and Galloway Respiratory Managed Clinical Network.

Version: 2

Approved By: National Guidelines