Asthma — Children

The anti-inflammatory reliever (AIR) shift described on the adult/adolescent management page is not TGA-approved for children aged 6–11 — SABA remains the appropriate reliever for this age group.

Diagnosis by age band

Infants (0–12 months): asthma should not be diagnosed. Wheeze at this age is usually due to infection or floppy airways (“viral-induced wheeze” or bronchiolitis) — don’t use bronchodilators. Significant wheeze warrants referral to a paediatrician/paediatric respiratory physician.

Preschool wheeze (1–5 years): difficult to diagnose with confidence. Episodic respiratory symptoms with cough and wheeze are common under 3, and a high proportion of children who respond to bronchodilators at this age do not go on to have asthma.

• History: confirm there’s a genuine wheeze (observe the child, or ask parents to video an episode); check the symptom pattern (only with colds vs also with play/laughter); increased work of breathing; personal/family history of allergy or atopy. Young children may deny reduced exercise tolerance rather than describe breathlessness.
• Investigations: consider aeroallergen testing if there’s a history of recurrent wheeze with an identifiable avoidable trigger; CXR if symptoms are atypical or wheeze is localised.
• Treatment trial: for children >12 months with wheeze plus increased work of breathing, trial SABA (salbutamol 2–4 puffs PRN via spacer with mask). Rapid improvement supports the diagnosis.
• Indications for preventer therapy: severity of flare-ups (ever needed ED care or oral corticosteroids) OR frequency (SABA needed weekly or more; consider if every 4–6 weeks).

School age (6+ years): history and examination as above, plus lung function testing.

• Spirometry is commonly normal when asymptomatic. Reduced FEV1/FVC for age indicates expiratory airflow limitation; bronchodilator response is defined as an FEV1 increase of ≥12% after 2–4 puffs of salbutamol.
• Bronchial provocation testing is difficult under age 8 but can help investigate exercise-induced wheeze — discuss with paediatrics/paediatric respiratory before ordering.
• Start a 4–6 week treatment trial if all of: wheeze with breathing difficulty, other features supporting asthma, a clinically important bronchodilator response on spirometry, and no signs/symptoms suggesting an alternative diagnosis.

Assessing severity and indications for preventer therapy

	Infrequent intermittent (flare-ups ≤6-weekly, no interval symptoms)	Frequent intermittent (flare-ups >6-weekly, no interval symptoms)	Persistent (any of: daytime symptoms >weekly, night symptoms >2×/month, symptoms restrict activity/sleep)
Mild flare-ups (almost always managed with salbutamol in the community)	Not indicated	Consider	Indicated
Moderate–severe flare-ups (>2 in the past year needing ED/oral corticosteroids)	Consider	Indicated	Indicated
Life-threatening flare-ups (hospitalisation or PICU)	Indicated	Indicated	Indicated

In summary, preventer therapy is indicated for: any persistent asthma; any life-threatening flare-up ever; >2 moderate/severe flare-ups (ED/steroids) in the past year; and considered for mild flare-ups occurring 6-weekly or more.

Preventer therapy

Children aged 1–5: low-dose ICS (particularly if symptoms are more severe, restrict activity, or age 1–2) or montelukast (particularly if allergic rhinitis is present — only 20–30% of children respond, so reassess at 4–6 weeks). Warn parents of montelukast’s rare but recognised neuropsychiatric adverse effects (anxiety, sleep disturbance, nightmares, irritability, aggression, depression). Step up to ICS+montelukast or a higher paediatric ICS dose if control is inadequate; refer to paediatric respiratory if still uncontrolled.

Children aged 6+: stepwise approach —

1. SABA reliever as needed (salbutamol 100mcg, 1–2 puffs).
2. Add low-dose ICS (e.g. fluticasone 50–100mcg BD, or ciclesonide 80mcg once daily) or montelukast, or a cromone.
3. Step up to high-dose ICS, or ICS + low-dose LABA (LABAs are approved from age 6), or ICS + montelukast.
4. Refer to paediatric respiratory/paediatrician.

Start a reliever-needed-≥2×/week (or always pre-exercise) threshold as the trigger to start a preventer. Step down after 6 months of good control — but not at the start of the school year or going into winter, the child’s peak asthma season. If well controlled on the lowest ICS dose, consider stopping (back to SABA-only) or switching to montelukast.

Flare-up management

Consider oral corticosteroids if a flare-up requires SABA roughly every 4 hours, or if severe symptoms are present: prednisolone 1mg/kg for 5–10 days, no taper needed — continue the regular preventer alongside. There’s no evidence in children for using an increased inhaled steroid dose instead.

For known reactive children (symptoms with colds), an action plan may specify 2–4 puffs salbutamol QID when unwell, escalating to 4–6 puffs 4-hourly if severe.