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: Asthma & Lung UK

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
  • Rattily 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: Alternative diagnoses in wheezy children | Right Decisions 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 to 12 week trial of low-dose ICS (i.e. Clenil 50 microgram: 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
  • Check inhaler technique and adherence
  • Check whether there is an environmental source for their symptoms
  • Consider referral to Paedatrics
  • Stop ICS
  • Review symptoms after 3 months

⇓

At 3 month review

Symptoms recurring or acute episode requiring systemic corticosteroids or hospitalisation

No recurrence
  • Code for 'Suspected Asthma'
  • Restart regular maintenance therapy: low / moderate dose ICS (Clenil 50 microgram 1 to 2 puffs twice daily)
  • Watchful waiting

If symptoms persist:

  • Contact Paediatrics via clinical dialogue / referral.
  • Consider commencing LTRA (montelukast: 4mg once daily, dose to be taken at night) for a trial of 8 to 12 weeks, counselling parents/ carers on side-effects. Stop if ineffective or side effects.

Maintenance

Nurse-led asthma clinic every 4 to 6 months

Monitoring check / discuss:

  • Number of asthma attacks 
  • Oral corticosteroid use
  • Time off nursery/ school
  • Nocturnal symptoms
  • Adherence/ correct use
  • Possession of up-to-date Child Asthma Action 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.

Patient information

Further information for health care professionals

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

Editorial Information

Last reviewed: 28/03/2025

Next review date: 31/03/2028

Author(s): Paediatrics.

Version: 2

Approved By: TAM subgroup of the ADTC

Reviewer name(s): Dr S Ghayyda, Consultant Paediatrician, Dr R Hampton, GPST.

Document Id: TAM654

Related resources

Further information for Health Care Professionals

References

Further information for patients

Evidence method

Clinical Governance Checklist