Asthma in children aged 2 to 5 years (Paediatric Guidelines)

TAM (Treatments and Medicines) NHS Highland
NHS Highland

Audience

  • Highland HSCP only
  • Primary only
  • Children only

Assessment

Under 2 years old ⇒ Refer to Paediatrics

2 to 5 years old:

Patient has more specific symptoms:

  • Documented recurrent wheeze (documented in medical notes by qualified medical practitioner, or
    evidence on video).
  • Recurrent episodes (2 to 3 times) of wheeze triggered by exercise, pollens, exposure to cold weather, giggling \ laughing or viral-induced wheeze.
  • Having increased work of breathing +/- wheeze at rest.
  • Increased WOB / wheezing improves with trials of salbutamol / ICS.

AND / OR Patient has less specific symptoms:

  • Parent or sibling with diagnosed asthma on an ICS.
  • Night-time chesty / dry cough.
  • Cough only triggered by cold weather, pollens, giggling (cough variant asthma is very rare in children).

At diagnosis check / discuss

  • Centiles (height and weight)
  • Up-to-date immunisations
  • Avoiding triggers, including passive smoking. Provide support for stopping
  • Personalised asthma action plan. See: Asthma & Lung UK
  • How to use the inhaler and spacer. See: YouTube: Aero chamber educational video

Red Flags

  • Failure to thrive
  • Unexplained clinical signs (focal signs, abnormal voice/cry, dysphagia, and/or inspiratory stridor)
  • Symptoms from birth
  • Excessive vomiting/posseting
  • Evidence of severe respiratory tract infection
  • Persistent/chronic/recurrent wet/productive cough
  • Rattly chest (secretions)
  • Family history unusual chest disease
  • Nasal polyps
  • Haemoptysis
An expiratory polyphonic wheeze on examination would help diagnosis but a normal examination does not exclude a diagnosis of asthma.
See: British guideline on the management of asthma page 24, for a table summarising clinical clues for alternative diagnoses in wheezy children.

Treatment initiation

Prescribe:

  • SABA (salbutamol 100microgram 2 to 10 puffs as required)
  • Alongside an 8-week trial of moderate dose ICS (i.e. Clenil 50microgram 2 puffs twice daily)

After the trial, once the diagnosis of asthma is suspected, provide asthma action plan for management of exacerbations.

⇓

Symptoms improve on trial?

No

Yes
  • Consider alternative diagnosis
  • Consider referral to Paeds
  • Stop ICS
  • Review at 4 weeks

⇓

At 4-week review

Symptoms recurring

No recurrence
  • Code for 'Suspected Asthma'
  • Prescribe maintenance therapy: low/ moderate dose ICS (Clenil 50microgram 1 to 2 puffs twice daily)
  • If ICS is contraindicated or not tolerated, a LTRA would be an alternative treatment at this point.
  • Watchful waiting
  • If symptoms worse after 4 weeks: RESTART

If symptoms persist:

  • Contact Paediatrics via clinical dialogue / referral).
  • Consider commencing LTRA (montelukast 4mg once daily, dose to be taken at night).
  • Review at 4 to 8 weeks.
  • Counsel parents/ carers on side effects.

Maintenance

Nurse-led asthma clinic every 4 to 6 months

Monitoring check / discuss:

  • Number of asthma attacks (consider ‘aims in treating’)
  • Oral corticosteroid use
  • Time off nursery/ school
  • Nocturnal symptoms
  • Adherence/ correct use
  • Possession of up-to-date self management plan
  • Exposure to tobacco smoke or other triggers
  • Centiles (height and weight)

When asthma is controlled expect:

  • No daytime symptoms
  • No night-time wakes due to asthma
  • No rescue meds/ asthma attacks
  • No limits on activity
  • No oral steroids
  • No OOH attendances/ hospital admissions

If control achieved for 6 to 12 months: aim to reduce maintenance dose ICS to the ‘lowest dose required for effective asthma control’.

  • Reduce ICS dose slowly: 25% reduction at 4 to 6-week intervals.
  • If remain well and completely symptom free for 6 to 12 months: consider trial without ICS inhaler.

Objective tests: used to diagnose asthma in older age groups (FeNO, Spirometry, PEFR) have little value in this age as children are too young to perform them accurately.

  • In this age group diagnosis is clinical.
  • Document and code 'Suspected Asthma' until objective tests performed.
  • Perform objective testing (if available in your practice, but not mandatory unless diagnosis is in doubt) once 5 to 6 years old.
  • If still unable to be performed, consider every 6 to 12 months until it is possible to carry them out accurately.

ABBREVIATIONS

  • FeNO: Fractional exhaled nitric oxide
  • ICS: Inhaled corticosteroid
  • LTRA: Leukotriene receptor antagonist
  • OOH: Out of Hours
  • PEFR: Peak expiratory flow rate
  • SABA: short-acting beta agonist
  • WOB: Work of breathing

References

Editorial Information

Last reviewed: 12/08/2024

Next review date: 31/08/2027

Author(s): Paediatrics.

Version: 1

Approved By: Approved by TAMSG of the ADTC

Reviewer name(s): Dr H Henderson, GP, Dr L Jones, GPST, Dr S Ghayyda, Consultant Paediatrician.

Document Id: TAM654

Related resources

Further information for Health Care Professionals

References

Further information for patients

Evidence method

Clinical Governance Checklist